Aim:  The outcome of surgery for colorectal cancer in each unit in the UK is collated by the National Bowel Cancer Audit Project (NBOCAP). In 2008/2009 our unit had,a raw 30 day postoperative mortality close to the national average, but when it was nationally adjusted, it appeared to be an outlier. The purpose of this study was to identify reasons for this disparity.

Method:  All records for patients undergoing surgery for colorectal cancer over the two years. Data submitted to NBOCAP to determine adjusted rates were compared with actual data.

Results:  There were major discordances between submitted and actual data for American Society of Anesthesiology (ASA) grades and timing of surgery. This explained why the unit appeared to be an outlier.

Conclusion:  There is increasing emphasis on outcome of health service delivery, which has important implications. Submission of correct data is essential if objective comparison is to be made on which to base decisions on service delivery among units and within health regions.

Aim:  Laparoscopic and open rectal resection for cancer were compared analyzing a total of 26 end points which included intraoperative and postoperative recovery, short-term morbidity and mortality, late morbidity and long term oncologic outcome.

Methods:  We searched for published randomized clinical trials, presenting a comparison between laparoscopic and open rectal resection for cancer by using the following electronic databases: Pub Med, OVID Medline, Cochrane database of systematic reviews, EBM reviews, CINAHL and EMBASE.

Results:  Nine randomized clinical trials (RCT) were included in the meta-analysis incorporating 1,544 patients with 841 having laparoscopic 703 open rectal resection for cancer. Laparoscopic surgery for rectal cancer was associated with a statistically significant reduction in intraoperative blood loss and in the number of blood transfusions, earlier return of bowel function and a shorter duration of hospital stay. We also found a significant advantage for laparoscopy in the reduction of wound infection, post-operative intra abdominal bleeding, late intestinal adhesion obstruction and in the late morbidity. No differences were found in terms of intra-operative and late oncologic outcomes.

Conclusion:  The metanalysis indicates that laparoscopy benefits patients, with shorter hospital stay, earlier return of bowel function, reduced blood loss, number of blood transfusion and lower rates of wound infection, intra-abdominal postoperative bleeding, late intestinal adhesion obstruction and other late morbidity.

Background:  Hemorrhoidectomy usually causes moderate to strong postoperative pain. Chinese studies have found that acupuncture may have an analgesic effect in post-hemorrhoidectomy patients. This is the first Western study to assess the efficacy of acupuncture as an adjunct analgesic therapy after stapled hemorrhoidopexy.

Methods:  In a randomized controlled trial, 50 patients were allocated to three groups. Conventional drug therapy (oral diclofenac and metamizol, local lidocaine) served as baseline analgesia. In the control group (n= 17), only this regimen was used. In addition to baseline analgesia, 17 patients received verum acupuncture. Sham acupuncture was performed on 16 patients. Being the primary outcome measure, pain was measured twice daily using the numerical rating scale (NRS) and compared statistically by repeated-measures analysis of variance. The study was registered (DRKS00003116).

Results:  After verum acupuncture, pain intensity was not significantly lower when compared to conventional analgesia (primary hypothesis, p= 0.057), but was when compared to sham acupuncture (p= 0.007). In the afternoon of postoperative day 1, for example, NRS was 2.7 (SD 1.5) in the verum group, but 4.0 (1.0) in the sham group and 4.1 (1.9) under conventional analgesia. Furthermore, significantly less rescue analgesics were necessary, if verum acupuncture was applied. Cardiovascular parameters were stable in all three groups, and no complications were recorded.

Conclusions:  In post-hemorrhoidectomy patients, acupuncture appears to be an effective adjunct to conventional analgesia. Further studies are necessary to confirm these observations and to refine acupuncture technique.

Aim:  With fast track surgery and shorter hospital stay, discharge from hospital after cancer surgery is becoming more challenging for the individual patient. The aim of this study was to explore how patients perceive information after surgery for colorectal cancer, what their information needs are and to determine factors affecting received information.

Method:  One hundred patients filled in the questionnaires EORTC QLQ-C30, CR38, INFO25, ECOG and SOC and provided written comments within the first two weeks after discharge following surgery for colorectal cancer. The questionnaires were analyzed using hierarchical cluster analysis and a multiple linear regression analysis. The written comments were analysed using content analysis.

Results:  Forty-nine percent of the patients expressed a need for more information. In the written comments they specified these areas of information: they lacked information concerning their surgery, how to handle symptoms and problems at home, someone to contact after discharge and prognostic information about their future. Patients reported most received information in areas of medical tests and disease but less on other services and support in outpatient care. The variation in INFO25 was best explained by gender (p=0.045) and preoperative health status (ASA 3 p=0.022).

Conclusion:  The results from this study indicate that women and patients with a poorer preoperative health status scored less on information received and would need more time and support to prepare for discharge. The patients expressed a desire for more information about the surgery, how to handle symptoms at home and prognostic information about their future.

Aim:  The study evaluated the effect of a loose-seton technique for perianal necrotizing fasciitis.

Method:  The medical records of seven patients with perianal necrotizing fasciitis treated by the loose-seton technique between December 2005 and June 2010 were reviewed. Age, gender, status of diabetes mellitus, duration of symptoms, the length of hospital stay and number of debridements were investigated.

Results:  Five patients were male. The mean age was 53 years and the rangewas 43∼79 years. All seven patients had a past history of acute perianal abscess. Six (85.7%) patients had diabetes mellitus. The mean time for removal of the seton was 24 (14-32) days and the mean hospitalization time was 31 (23–45) days. All patients had primary wound healingl. There was no mortality. At a median follow-up 18(6 -60) months, one patient required inpatient treatment with cutting-seton for complex anal fistula after 11 months. All patients had normal faecal continence and none of them required reconstructive procedure during the follow-up.

Conclusion:  The loose-seton technique is an effective treatment for perianal necrotizing fasciitis. The advantages include inhibiting spread of inflammation, reducing the frequency of debridements, decreasing the area of the wounds, and limiting extensive scar formation.

Aim:  There has been controversy about the presentation and treatment of acute colonic diverticulitis (AD) in young patients. The aim of this observational study was to evaluate the virulence and natural history of AD in three different age groups of patients.

Method:  The study was performed on 686 patients with the diagnosis of a first episode of AD admitted between January 1998 and December 2008. Patients were classified into three groups: age 45 years old or younger (group 1), 45 to 70 years of age (group 2) and 70 years or more (group 3). The variables studied were gender, American Society of Anaesthesiologists status, associated co-morbidity type of treatment, length of hospital stay and recurrence of AD.

Results:  Group 1 included 99 (14.4%) patients, group 2, 339 (49.4%) and group 3, 248 (36.2%). One hundred and forty four patients needed emergency operation at the first admission, 25 underwent elective surgery after the first episode of AD and 10 died after medical treatment. Five-hundred and seven patients were followed for recurrence. One-hundred and four patients (20.5%) had a recurrence of AD that required hospitalization. Fifty (9.9%) presented with one episode of severe recurrence, without any difference between the groups (p=0.533). There were no differences in the analysis of cumulative recurrence (Kaplan-Maier) between the three groups.

Conclusion:  Acute diverticulitis does not present a more aggressive clinical course in younger patients and it can be safely managed using the same strategy as in middle aged and older patients.

Aim:  Available guidelines from NICE & ACPGBI recommend combined (medical + mechanical) thrombo- prophylaxis. A Cochrane library review recommends self-administered low molecular weight heparin (LMWH) for 2- 3 weeks following surgery. In the light of the recent guidelines from ACPGBI and NICE, we undertook a national questionnaire survey aimed to assess current thrombo-prophylaxis practice among colo-rectal surgeons in the UK.

Method:  A 10 item questionnaire was designed to enquire into the current management strategy of post-operative thrombo-prophylaxis. The postal questionnaire survey was sent to all 490 active consultant ACPGBI members.

Results:  Of 490 questionnaires, 259(52.8%) were returned fully completed. Among these 259 (100%) routinely used thrombo-prophylaxis, with 243(93.8%) using departmental guidelines. Combined medical and mechanical prophylaxis was used by 247 (95.40%) responders. A small proportion, 12 (4.6%), used medical-prophylaxis only. LMWH was the preferred medical-prophylactic agent in 243 (93.8%). The majority, 176 (68%), started thrombo-prophylaxis on admission and stopped it at discharge. Seventy one (27.4%) respondants recommended thrombo-prophylaxis after hospital discharge for an average duration of 4 – 6 weeks, preferring graduated compression stockings followed by LMWH.

Conclusion:  The National Questionnaire Survey on thrombo-prophylaxis demonstrated a high degree of concordance with the available guidelines except that the duration of thrombo-prophylaxis be continued post-operatively for a period of 28 days/ 4 weeks.

Aim:  The purpose of this study was to determine treatment characteristics and clinical outcome of patients with perineal hernia after abdomino-perineal resection (APR).

Method:  Systematic search of literature revealed 40 individually documented patients, published between 1944 and 2010. Three additional patients treated at our centre were added. Patient characteristics, type of repair and outcome were entered into a database and a pooled analysis of these 43 patients was performed.

Results:  Pooled analysis revealed a median time interval of 8 months between APR and surgical repair of perineal hernia. The surgical approaches were perineal in 22 patients, open abdominal in 11, open abdomino-perineal in 3, laparoscopic in 5 and laparoscopic-perineal in 2 patients. A primary recurrence was documented in 13 patients and a second recurrence in three. The recurrence rate was 5/25 for synthetic or biological mesh, 6/12 for primary closure and 2/6 for the remaining techniques. Recurrent perineal hernia was repaired using a synthetic or biological mesh (N=6), primary closure (N=5) or a muscle flap (gluteus or gracilis; N=4).

Conclusion:  From this limited and biased data based on published case descriptions, it appears that the recurrence rate of primary perineal hernia repair after APR is lower with the use of a mesh or other assisted closure in comparison to primary suture repair.

Aims:  Enhanced recovery programmes (ERP) after colorectal surgery are promoted to minimise complications and expedite recovery, thus reducing length of hospital stay where appropriate and improving the overall standard of patient care. There are few published trials of ERPs in the context of laparoscopic colorectal surgery.

Methods:  Data was prospectively collected on all laparoscopic colorectal resections carried out in our institution from May 2004 to November 2009. An informal move to 48 hour discharge was introduced in May 2004 and the official ERP launched in November 2008. We identified all patients with a primary anastomosis discharged within 3 days of surgery. Early outcomes: leaks, complications, readmission rates and returns to theatre were analysed.

Results:  606 resections were performed in this period. Median length of stay was four days (0-52). 279 patients met the criteria of accelerated discharge by day 3 (46%). Of these patients, two (0.7%) were discharged on the day of surgery, 70 (25.1%) within 24 hours, 116 (41.6%) within 48 hours and 91 (32.6%) by 72 hours. Age was not a significant factor in determining length of stay. Patients undergoing right hemicolectomy were more likely to be discharged by 24 hours than those with left-sided anastomoses and patients having TME resections were more likely to stay 3 days. The readmission rate was 4%, regardless of day of discharge.

Conclusion:  Accelerated discharge is feasible and safe. High readmission rates reported in ERPs after open colorectal surgery have not occurred in our laparoscopic experience.

Aim:  Immunosuppression and steroid medication have been identified as risk factors for complicated sigmoid diverticulitis. The underlying molecular mechanisms have not yet been elucidated. We hypothesized that glucocorticoid-induced TNF Receptor (GITR) and Matrix Metalloproteinase-9 (MMP-9) might play a role.

Method:  GITR and MMP-9 were analyzed on protein (IHC/IF) and mRNA level (RT-PCR) in surgical specimen with complicated and non-complicated diverticulitis (n=101). Immunofluorescence (IF) double staining and regression analysis were performed for both markers. GITR expression was correlated with clinical data and its usefulness as diagnostic test was investigated.

Results:  High GITR expression (x≥41%) was observed in the inflammatory infiltrate in complicated diverticulitis, in contrast to non-complicated diverticulitis where GITR expression was low (p<0.001). High GITR expression was significantly associated with steroid use and pulmonary diseases (both p<0.001). MMP-9 expression correlated with GITR expression (R²=0.7268, p<0.0001, r=0.85) as demonstrated with IF double staining experiments. Co-labeling of GITR with CD68, but not CD15, suggested that GITR-expressing cells in diverticulitis are macrophages. GITR expression was superior to C-reactive protein (CRP), white cell count (WBC) and temperature in distinguishing complicated and non-complicated diverticulitis.

Conclusions:  Our results suggest that GITR expression in inflammatory cells might potentially indicate a molecular link between steroid use and complicated forms of acute sigmoid diverticulitis. Increased MMP-9 expression by GITR signaling might explain the morphological changes in the colonic wall of perforated and phlegmonous diverticulitis. Analysis of soluble GITR (sGITR) might be a promising strategy for future research.

Aim:  Single access laparoscopic surgery is a recent vogue in the field of minimally invasive colorectal surgery. While selected series have indicated feasibility, we prospectively examined its usefulness for resectional surgery in routine practice.

Method:  All patients undergoing laparoscopic colorectal resection over a twelve month period were considered for a single access approach by a single surgical team in a university hospital. This utilised a ‘Glove’ port via a 3-5 cm periumbilical or stomal site incision with standard rigid laparoscopic instruments then being used.

Results:  Of 74 planned laparoscopic colorectal resections, 35 (47%) were performed by this single incision laparoscopic modality without disruption of theatre list efficiency or surgical training obligations. The mean (range) age and BMI of these 25 consecutive right sided resections, 8 total colectomies (7 urgent operations) and 2 anterior resections was 58 (22-82) years and 23.9 (18.6-36.2) kg/m² respectively. The modal postoperative day of discharge was 4. For right sided resections, the mean (range) post-op stay in those undergoing surgery for benign disease was 4, while for those undergoing operation for neoplasia (n=18, mean age 71 years) it was 5.8 days and the average lymph node harvest was 13. Use of the glove port reduced trocar cost by 58% (€60/£53) by allowing use of trocar sleeves alone without obturators.

Conclusion:  Single incision laparoscopic surgery is an effective option for abdominal surgery and seems especially suited for laparoscopic-assisted right sided colonic resections. The Glove port technique facilitates procedural frequency and familiarity and proves economically favourable.

Aim:  Selected patients were studied with haemorrhoidal prolapse undergoing stapled anopexy with the double PPH-03 technique.

Method:  Between March 2007 and March 2010, 235 patients referred with haemorrhoids were included in the study. Patients with obstructed defecation were excluded. At surgery intraoperative evaluation for double stapled anopexy was carried out based on the criteria of prolapse occupying half or more of anal circumference and redundant prolapsed tissue determined by the circular anal dilator (CAD). Patients fulfilling these criteria were submitted to double stapled anopexy with PPH-03. All clinical and operative data were recorded in a prospectively maintained database.

Results:  Among the 142 patients with haemorrhoidal prolapse having surgery 91 had a single and 51 a double stapled technique (2-PPH03). The mean operative time was 34.8 minutes with no major or minor intraoperative complications. Recurrence at 48 months was 1.9%. and the mean satisfactio score was 8.9.

Conclusion:  The double stapled PPH-03 technique in selected cases was equally safe and effective compared with a single stapling technique with a lower incidence of recurrence over a median term follow-up.

Aim:  The surgical treatment of complex anal fistula remains controversial, although “sphincter-saving” operations are desirable. The Gore Bio-A® Fistula Plug is a new bioprosthetic plug that has been proposed for treatment of complex anal fistula. This study reports preliminary data following implantation of this plug.

Method:  Eleven patients with complex anal fistula underwent insertion of Gore Bio-A® Fistula Plugs. The disk diameter and number of tubes in the plug were adapted to the fistula, so that the disk was accommodated into a submucosal pocket and the excessive tubes were trimmed. During the follow-up, patients underwent clinical and physical examination and 3D-endoanal ultrasonography.

Results:  Fistulas were high anterior transphincteric in five patients and high posterior transphincteric in six patients. All patients had a loose seton placement before plug insertion. Two, three, and four tubes were inserted into the fistula plug in 7, 3, and one patient. The median follow-up period was 5 months. No patient reported any faecal incontinence. There was no case of early plug dislodgement. Success of treatment was noted in 8 (72.7%) of 11 patients at the last follow-up.

Conclusion:  Implanting a Gore Bio-A® Fistula Plug is a simple, minimally invasive, safe and potentially effective procedure to treat complex anal fistula. Patient selection is fundamental for success.

Aim:  The study is a retrospective review of the short term outcome of all elective rectal resections in 114 consecutive octogenarian patients during the 10 year period January 2000 to December 2009.

Method:  60 laparoscopic and 54 open resections were completed. The two groups were evenly matched for age (mean 83 yrs) and ASA (mean 2.5) and pathology (malignancy 60%).

Results:  Morbidity and mortality were comparable with no significant differences. Only length of stay in uncomplicated recoveries were significantly different in favour of laparoscopic surgery at 10 versus 14 days p<0.003.

Conclusion:  Laparoscopic rectal resection is suitable for octogenarians.

Aim:  Brain metastasis is infrequent in colorectal cancer patients, and the prognosis is poor. In this retrospective study survival and prognostic factors were determined in patients with brain metastasis from colorectal cancer.

Method:  Between 1997 and 2006, 39 patients with brain metastasis from colorectal cancer who survived more than one month were identified. Data were collected with regard to patient characteristics, location, and stage of the primary tumour, extent and location of metastatic disease, and treatment modalities used.

Results:  Most (79.5%) patients had pulmonary metastases before brain metastasis, and the brain was the site of solitary metastasis in only one patient. The most frequent symptom was weakness (18 (43.6%) patients). Overall median survival was 5.0 months and the 1- and 2-year survival rates were 21.8% and 9.1%, respectively. Univariate analysis revealed uncontrolled extracranial metastases (P = 0.019), multiple brain lesions (P = 0.026), bilateral brain metastases (P = 0.032), and serum CEA levels greater than 5 ng/ml (P = 0.008) to be poor prognostic factors. The median survival after the diagnosis of brain metastasis was significantly longer in patients who underwent surgical resection (15.2 ± 8.0 months) than in those treated by other modalities (P = 0.001). Treatment modality was the only independent prognostic factor for the overall survival in patients with brain metastases from colorectal cancers (P = 0.015)

Conclusion:  Aggressive surgical resection in selected patients with brain metastases from colorectal cancer may prolong survival, even in the presence of extracranial metastatic lesions.

Aim:  Primary care referral for patients with bowel symptoms are triaged by general practitioners to urgent or routine based on the clinical suspicion of malignancy. Triage directly influences time to assessment and investigation. The study aimed to establish whether urgency of referral of patients with large bowel malignancy has any effect on management.

Method:  An analysis was undertaken of all patients with colorectal cancer referred by primary care and discussed at the regional colorectal multi-disciplinary team (MDT) meetings from January 2009 to December 2010. Demographics and tumour data were collated prospectively from MDT records, and operation and investigation reports.

Results:  Of 369 primary case referrals with colorectal cancer, 303 (82.1%) were urgent and 66 (17.9%) routine. Patient characteristics (age, sex, ASA grade) and resection rates were similar in both groups and no significant difference in tumour location was observed. The time from referral to diagnosis was significantly longer in the routine cohort (mean 73.7 days versus 30.2 days (p=0.001). Dukes’ stage was less advanced for the routine referral group, (p=0.002)

Conclusion:  Urgency of referral decreased the time to diagnosis. This did not influence resection rates. Dukes’ stage was higher for urgent referrals. Long term follow up is required to determine any impact on survival.

Aims:  South Asians comprise 13.6% of the Wolverhampton population. We aimed to compare the incidence and trend of colorectal cancer in this subgroup with the non-South Asian population over a 20 year period.

Method:  Patients of South Asian origin diagnosed with colorectal cancer from 1989 to 2008 were identified from the hospital histopathology database and compared to those of non-South-Asian origin. 1991 and 2001 census data were used to standardise for differing age and sex distributions in the two study populations.

Results:  The median unadjusted incidence of colorectal cancer from 1989 to 2008 was 6.17/100,000/year in South Asians compared to 71.70/100,000/year in non -South Asians (77.79% white British). The age and sex adjusted odds ratio for colorectal cancer in South Asians was 0.2 (p <0.001). There was an equal increased trend in the incidence in both the South Asians and non-South Asians over the study period (0.8%/year). In patients <50 years, the gender difference in the incidence of cancer was not significant, but as age increased,this rose significantly (males > females).

Conclusion:  There was a markedly lower incidence of colorectal cancer in South Asians compared to non-South Asians, maintained over 20 years. Colorectal cancer incidence increased by a small and similar, amount over the period in both groups. There was a male preponderance of colorectal cancer in both populations over 50 years.

Aim:  A poor functional outcome is often reported after total mesorectal excision (TME) for rectal cancer, especially when sphincter-saving resection with intersphincteric dissection is performed for low tumours. Anal sphincter rehabilitation is widely proposed for faecal incontinence. Very few studies have reported results to improve anal dysfunction following rectal surgery. This prospective study aimed to assess the benefits of sphincter training after TME in terms of functional outcome and quality of life.

Methods:  Anal sphincter training was performed in patients undergoing laparoscopic sphincter-saving TME for rectal cancer. Rehabilitation was performed after ileostomy closure. This group was compared with 24 matched patients. Assessment included one functional and two quality-of-life questionnaires (SF-36 Health Status and Faecal Incontinence Quality of Life score).

Results:  From 2007 to 2009, 22 patients underwent laparoscopic TME. The median follow-up after stoma closure was 21.2 (range, 8-46) months. The mean stool frequency per day was significantly lower after sphincter training (2.6 in the training group versus 4.0 in the control group, P=0.025). Following rehabilitation, patients complained significantly less about dyschesia (22 versus 63%, P=0.008). Both groups had similar continence (Wexner score: 8.3 after training versus 9.9 in controls, NS). Quality of life was significantly improved by sphincter training as measured by the vitality (P=0.004) and mental functioning (P=0.02) subscales on the SF-36 Health Status questionnaire and by the depression and self-perception (P=0.005) categories of the Faecal Incontinence Quality of Life score.

Conclusion:  This study suggests that anal sphincter training following TME could decrease stool frequency and improve both general and specific quality of life.

Background:  Surgical site infection (SSI) remains a common post-operative morbidity, particularly colorectal resections, and poses a significant financial burden to the healthcare system. Omitting mechanical bowel preparation, as is performed in enhanced recovery after surgery programmes, appears to further increase the incidence.Various wound protection methods have been devised to reduce the incidence of surgical site infections. However, there are few randomized controlled trials assessing their efficacy.The aim of this study is to investigate whether ALEXIS wound retractors with reinforced O-rings are superior to conventional wound protection methods in preventing surgical site infections in colorectal resections.

Methodology:  Patients undergoing elective open colorectal resections via a standardized midline laparotomy were prospectively randomized to either ALEXIS or conventional wound protection in a double-blinded manner. A sample size of 30 in each arm was determined to detect a reduction of surgical site infection from 20% to 1% with a power of 80%. Secondary outcomes included post-operative pain.

The operative wound was inspected daily by a specialist wound nurse during admission, and again 30 days post-operatively. Statistical analysis was performed using SPSS v13 with p<0.05 considered significant.

Results:  Seventy two patients were recruited into the study but eight were excluded. There were no SSI in the ALEXIS study arm (n=34) but six superficial incisional SSI (20%) were diagnosed in the control arm (p=0.006). Post-operative pain score analysis did not demonstrate any difference between the two groups (p=0.664).

Conclusion:  The ALEXIS wound retractor is more effective in preventing SSI in elective colorectal resections compared to conventional methods.

Aim:  Sentinel lymph node (SN) mapping for staging in colorectal cancer remains controversial and needs to be validated before it can be implemented in daily practice. We prospectively assess the effect of SN mapping on nodal staging and its implication on survival in patients with colorectal cancer.

Method:  Between November 2005 and July 2009, 331 patients underwent a resection for colorectal cancer. In 189 patients (group A) an ex-vivo SN procedure was performed with immunohistochemical analysis of the SN. Tumour cell deposits between 0.2 mm and 2.0 mm were referred to as micrometastases (pN1mi+). The remaining patients (n=142, group B) had standard nodal staging. Multivariate cox regression analysis was performed to identify prognostic factors for disease recurrence.

Results:  The average number of harvested lymph nodes was higher in group A compared to group B (15.5 ± 7.3 versus 12.1 ± 5.2, p<0.0001). After conventional staging, 81 (43%) patients had nodal metastasis in group A. This increased to 89 (47%) patients when immunohistochemically detected micrometastases were included. In group B 50 (35%) patients had nodal metastasis. During follow-up, a lower recurrence rate was seen in N0 patients after SN mapping compared with conventional staging group (4% versus 15.2%, p=0.04). The SN procedure (hazard ratio: 4.1) was an independent predictor of disease recurrence.

Conclusion:  The SN procedure results in a more accurate staging of patients with colorectal cancer. This is reflected by a better prognosis of N0 patients after SN mapping.

Aim:  The aim of this study was to review trainees’ opinions of the training they had received through the National Training Programme (NTP) .

Method:  An on-line questionnaire was distributed to NTP trainees who had completed five or more training episodes within the programme. Demographic data were collected. Opinion was given using a 5-point Likert scale (1=strongly disagree, 3=undecided, 5=strongly agree). Percentages, mean values and standard deviations were presented. Analysis of variance (ANOVA) and Mann-Whitney U tests were used to examine the impact of different factors on ratings and the difference between ratings respectively.

Results:  Fifty-four registered trainees fulfilled the inclusion criteria, and thirty-seven (69% response rate) completed the questionnaire. Teaching sessions were organised using either an inreach (11%), in-house (11%), outreach (27%), or combination system (51%) of training. Trainees felt that their trainers seldom canceled sessions (93%) and that it was easy to organise (92%) and consent (100%) the patient. Their hospital was supportive of training (97%). Trainees overall stated their trainers to be excellent at training (Likert scale 4.71 (±0.46)) and that they received regular feedback (87%). The only variable to have a significant impact on the level of NTP approval was whether the trainee was able to choose his or her trainer (supportive of NTP, chose trainer p=0.050; critical of NTP, chose trainer p=0.020).

Conclusion:  The large majority of trainees was highly satisfied with the training received in this innovative programme, irrespective of region or training structure used, thus demonstrating acceptability of the programme in its current form.

Aim:  Narrow-band imaging (NBI) is a novel imaging technology that makes the superficial vasculature of gastrointestinal mucosa visible. However the real accuracy for the differentiation of neoplastic from non-neoplastic polyps by NBI for colorectum is still unknown.

Method:  A meta-analysis was carried out of studies which assessed the precision of NBI on the diagnosis of colorectal neoplastic polyps. Searches included PubMed and Embase as two reviewers independently assessed their quality with a modified version of the QUADAS and STARD tools. The study pooled estimates of sensitivity, specificity, DOR and AUC.

Results:  There were 11 relevant original articles which fulfilled the inclusion criteria. The pooled sensitivity and specificity were 0.92 (95% CI 0.90- 0.93) and 0.83 (95% CI 0.81–0.86) respectively. And the AUC for NBI was 0.95[S.E. 0.01; DOR 53.72(95% CI 35.66–80.92)]. The sensitivity and specificity were 0.92 (95%CI 0.90-0.94) and 0.81 (95%CI 0.78-0.84) with magnification, and 0.91 (95% CI 0.88-0.93) and 0.86 (95% CI 0.82-0.89) without magnification. For the mucosal pattern sensitivity and specificity were 0.90 (95% CI 0.85-0.940) and 0.88 (95% CI 0.82-0.93) and for vascular pattern intensity, they were 0.92 (95% CI 0.90-0.94) and 0.88 (95% CI 0.83-0.91).

Conclusion:  Narrow-band imaging, with or without magnification, has a high diagnostic precision for colorectal neoplastic polyps using either vascular pattern intensity or mucosal pattern-based assessment as the measures.

Aim:  Despite the incidence of colorectal cancer increasing with age the proportion of patients undergoing surgery for colorectal liver metastases (CRLMs) decreases dramatically in the elderly. Is this referral or selection bias justified?

Method:  A prospective database of resection for CRLMs at a single centre was retrospectively analysed to compare the outcome in patients aged >75 years (Group E) with those aged <75 years (Group Y). Data were analysed using the Kaplan-Meier method with Cox regression modelling.

Results:  Of 1443 resections, 151 (10.5%) in Group E were compared with 1292 (89.5%) in Group Y. The two groups were matched apart from higher ASA scores (p=0.001) and less use of chemotherapy (p=0.01) in the elderly. Perioperative morbidity and 90-day mortality were higher in the elderly compared with the younger group (32.5% versus 21.2%, p=0.02 and 7.3% versus 1.3%, p=0.001). In the last 5 years, mortality in the elderly improved and was no longer significantly different from the younger patients (n=2/76 [2.6%] versus n=9/559 [1.6%]; p=0.063). The five-year survival was similar in Groups E and Y for cancer-specific (41.4% versus 41.6%, p=0.917), overall (37.0% versus 38.2%) and median survival (44.1 months versus 43.6 months, p=0.697) respectively.

Conclusion:  In the elderly liver resection for metastatic disease can be performed with acceptable mortality and morbidity with as good a prospect of survival as for younger patients.

Aim:  Accurate and reliable imaging of pelvic floor dynamics is important for tailoring treatment in pelvic floor disorders, however two imaging modalities are available. Barium proctography (BaP) is widely used, but involves a significant radiation dose. MR proctography allows visualisation of all pelvic midline structures but patients are supine. This project investigates whether there are measurable differences between BaP and MR proctography. Patient preference for the tests was also investigated.

Methods:  Consecutive patients referred for BaP were invited to participate (NRES-approved). Participants underwent BaP in Poole and MR proctography in Dorchester. Proctograms were reported by a consultant radiologist with pelvic floor subspecialisation.

Results:  71 patients were recruited. Both tests were carried out on 42 patients. Complete rectal emptying was observed in 29% (12/42) on BaP and in 2% (1/42) on MR proctography. Anismus was reported in 29% (12/42) on BaP and 43% (18/42) on MR proctography. MR proctography missed 31% (11/35) of rectal intussusception detected on BaP. In 10 of these cases no rectal evacuation was achieved during MR proctography. The measure of agreement between grade of rectal intussusception was fair (Kappa 0.260) although MR proctography tended to underestimate the grade. Rectoceles were extremely common but clinically relevant differences in size were evident. Patients reported that they found MR proctography less embarrassing but harder to empty their bowels..

Conclusions:  The results demonstrate that MR proctography under reports pelvic floor abnormalities especially where there has been poor rectal evacuation.

Aim:  Good functional outcome following Anterior Resection (AR) for rectal cancer is an important clinical goal but its prediction has proven difficult. Assessments such as anal manometry have been advocated as a potential tool but functional anatomy as depicted on MRI has not been investigated. This study looked at whether sphincter complex measurements recorded from pre-operative staging MRIs and pre-operative anal manometry have any correlation with functional outcome.

Method:  Consecutive patients with rectal adenocarcinoma underwent pre-operative manometric assessment and MRI staging. MRIs were assessed with regard to anorectal angle, puborectalis thickness, canal length, external (EAS) and internal anal sphincter (IAS) thickness. Functional outcome was categorized into 3 groups according to number of adverse post-operative symptoms (frequency, urgency, leakage, diarrhoea, use of pads, use of anti-diarrhoeal medication); 0,1 and ≥ 2. This was evaluated one year following surgery and 6 months following stoma reversal where applicable. Univariate analysis of an ordinal regression model was performed with significance at the 5% level.

Results:  30 patients were assessed. No single pre-operative manometric parameter proved significant (p>0.05). Only puborectalis thickness showed a significant (p=0.01) relationship with the number of adverse symptoms suffered post-operatively. On ROC analysis, a cut-off value of 3.5mm gave an optimal sensitivity of 0.5 (95% CI, 0.17-0.83) and specificity of 0.86 (95% CI, 0.64-0.96).

Conclusions:  Measurements of the puborectalis thickness on pre-operative staging MRIs for rectal cancer may help predict functional outcome following AR. Prospective assessment of larger numbers with a fully validated continence score are required to evaluate these findings further.

Purpose:  The role of biologic therapy in perianal fistulas associated with Crohn’s disease (CD) is uncertain as available data are confused and conflicting. In order to provide some clarity to the issue we have examined a large cohort of patients with perianal fistulas and CD and stratified them according to use of biologic agents.

Methods:  Patients with perianal Crohn’s fistulas treated between June 1999-2009 were stratified according to use of biologic agents and outcome was examined. Healing was defined as absence of fistula or drainage. Prior to surgery perianal sepsis was eradicated with drains or setons. Endpoints were defined as either complete healing, improvement (minimal symptoms and drainge) or unhealed, as noted at subsequent outpatient follow up. Variables assessed were age, body mass index, smoking, perineal involvement with Crohn’s granuloma and type of procedure. Fisher’s exact test and Chi-square test were used for analysis.

Results:  218 patients had anal fistulas and CD. Mean follow-up was 3.2±3 years with mean age 38.8±12.2 years and body mass index of 25.3±6. 117 patients (53.7%) underwent surgery alone (GroupA) and 101 patients (46.3%) underwent surgery and biological immunomodulators treatments (GroupB). Demographic data and CD history were similar between groups.Surgeries included seton drainge(n=90), fistulotomy(n=22), rectal advancement flap(n = 39), fistulotomy plus seton(n=47) and others(n = 20). Overall improvement in GroupA was in 42 patients(35.9%) versus 72 patients(71.3%) in GroupB(p=0.001). There was no significant difference in other studied variables between both groups.

Conclusions:  There is a definite role for biologic therapy as an adjuvant to surgery in patients with perianal; fistulas and CD.

Aim:  The study assesd the role of colorectal surgery in the treatment of metastatic melanoma and to identify patients who can most benefit from surgical resection.

Method :  A retrospective analysis was made of 34 consecutive patients with skin melanoma who underwent surgical resection of large bowel metastasis.

Results :  The median disease-free interval (DFI) between diagnosis of the primary and metastatic melanoma was 24 (7-98) months. Nine (27%) patients underwent emergency surgery for obstruction and twenty-five (73%) had an elective procedure. Resection with curative intent was performed in fourteen (41%) and palliative resection in twenty (59%) patients. There was no postoperative mortality and morbidity occurred in 9%. The median survival following surgery was 11.5 (4-68) months. The 1-, 2-, and 5-year survival rates were 50%, 32%, and 17% respectively. Median survival was significantly increased in patients without extra-abdominal metastases, with no evidence of non-large bowel metastases, if the DFI was longer than 24 months and when curative resection was performed. In multivariate analysis, an apparently complete or palliative resection and the absence or presence of extra-abdominal metastases were the most important prognostic factors.

Conclusion :  An aggressive surgical approach to large bowel metastatic melanoma results in good palliation and effective relief of symptoms with acceptable morbidity and mortality.

Aim:  The study aimed to assess quality of life (QoL) in patients with a sigmoid colostomy using a simple general and disease specific instrument. A subgroup not doing well was identified and examined further.

Method:  Short Health Scale (SHS) is a four-item instrument exploring severity of symptoms, function in daily life, worry, and general well-being, using visual analogue scales (VAS) ranging from 0 to 100 where 100 is the worst possible situation. SHS was delivered to 206 patients with a sigmoid colostomy. It was returned by 181 (87.9%) patients (88 men; median age 73(33-91) years. Follow-up was 61 (10-484) months for 178 (86,4%) patients returning usable questionnaires. A subgroup of 16 patients scoring more than 50 in all four items of SHS was further examined with StomaQOL where 100 is best possible.

Results:  The median score for severity of symptoms was 18 (2-95), function in daily life 21 (0-95), worry 17 (3-98), and general well-being 22 (0-99). A score less than 50 in SHS was recorded in 84.9%, 82.1%, 79.9%, and 70.5% respectively. In the group scoring more than 50 in all four items patients diagnosed with irritable bowel syndrome (IBS) constituted 43.8% to compare with 5.6% in the entire study group (p<0.001). Median score for StomaQOL was 37 (22-62) in this group.

Conclusion:  Most patients with a permanent sigmoid colostomy have a good QoL consistent with previous findings. However, this is reduced in a subgroup of patients diagnosed with IBS.

Aim:  Following treatment for colorectal cancer it is common practice for patients to attend hospital clinics at regular intervals for routine monitoring, although debate persists on the benefits of this approach. Nurse-led telephone follow-up is effective in meeting information and psycho-social needs in other patient groups. We explored the potential benefits of nurse-led telephone follow-up for colorectal cancer patients.

Method:  Sixty-five patients were randomised to either telephone or hospital follow-up in an exploratory randomised trial.

Results:  The telephone intervention was deliverable in clinical practice and acceptable to patients and health professionals. Seventy-five percent of eligible patients agreed to randomization. High levels of satisfaction were evident in both study groups. Appointments in the hospital group were shorter (median 14.0 minutes) than appointments in the telephone group (median 28.9 minutes). Patients in the telephone arm were more likely to raise concerns during consultations.

Conclusion:  Historical approaches to follow-up unsupported by evidence of effectiveness and efficiency are not sustainable. Telephone follow-up by specialist nurses may be a feasible option. A main trial comparing hospital and telephone follow-up is justified although consideration needs to be given to trial design and practical issues related to the availability of specialist nurses at study locations.

Aim:  The aim of this study was to characterize formally the mesocolic anatomy during and following total mesocolic excision. Total mesocolic excision may improve survival in patients with colon cancer. Although this requires a detailed knowledge of normal and variant mesocolic anatomy, the latter is poorly characterized. No studies have prospectively characterized the anatomy of the entire mesocolon.

Method:  Total mesocolic excision was performed in 109 patients undergoing total abdominal colectomy. The mesocolon was maintained intact thereby permitting a precise anatomic characterization from ileocaecal to mesorectal levels. Two and three dimensional schematic reconstructions were generated to illustrate in situ conformation.

Results:  Several previously undocumented findings emerged including: (a) the mesocolon was continuous from ileocaecal to rectosigmoid level, (b) a mesenteric confluence occurred at ileocaecal and rectosigmoid junction as well as at the hepatic and splenic flexures, (c) each flexure (and ileocaecal junction) was a complex of peritoneal and omental attachments to colon centred on a mesenteric confluence, (d) the proximal rectum originated at the confluence of the mesorectum and mesosigmoid and (e) a plane occupied by Toldt`s fascia separated the entire apposed mesocolon from the retroperitoneum.

Conclusion: When the mesocolon is fully mobilized during a total mesocolic excision of the colon, several anatomic findings that have not been previously documented emerge. These findings provide a rationalization of the surgical, embryologic and anatomic approaches to the mesocolon. This has implications for all related sciences.

Background  Emergency surgery is associated with higher mortality rates, especially in elderly patients presenting emergent colorectal disease. The aim of this study was to determine the outcomes in elderly patients following emergency colorectal resection in the elderly, with particular attention to octogenarians who presented a 6-fold mortality rate with respect to other patients.

Method  This study examined 355 patients who underwent surgery at an Emergency Department for complications of colorectal disease between January 2007 and December 2009. Morbidity and mortality were analyzed on the basis of patients’ characteristics and presentation.Univariate and logistic regression analysis were performed on morbidity and mortality risk factors.

Results  215 patients older than 65 years were included, ninety-three of whom were over 80 years of age.

The global mortality rate was 16%. In patients aged 80 or over, the mortality rate was 30%. The difference in mortality rates between patients aged under 80 versus 80 or older was 24%. Aged 80 years or over, ASA grade, colon ischemia, neurologic comorbidity and anastomosis dehiscence in resected patients were identified as independent risk factors for both univariate and logistic regression analysis.

The morbidity rate was approximately 17%, no difference between the two groups was found.

Conclusion  The results of this study show that fitness status and microvascular impairment impact significantly on mortality in the elderly, and particularly in octogeniarians. Although the outcomes observed were compatiblewith the literature, the 6 fold higher mortality rate observed in the most elderly patients identifiedpatients for which death prevention is best achieved with aggressive resuscitation and intensive post operative care,rather than timing of surgery.

Background:  Incidental appendectomy is a frequent but not standardized procedure during surgery for colorectal cancer. Performing an incidental appendectomy during colorectal resections is left to the discretion of the operating surgeon.

Methods:  This retrospective study used data from 1352 consecutive patients who underwent surgery for colorectal cancer between 1993 and 2009 at the Medical University of Vienna. The authors evaluated histopathological results of incidentally removed appendices. In addition, complications and expenses in terms of the additional intervention were analyzed.

Results:  In 314 (23.22%) patients previous appendectomy had been performedbecause of appendicitis. In 380 (28.11%) patients incidental appendectomy was performed and 86 (22.63%) of these patients showed completely normal histology of their appendix, in 289 (76.05%) patients a pathologic alteration and in 7 (1.84%) patients a neoplasm was found. No complications occurred from the additional surgical procedure. The costs and time effort were negligible.

Conclusion:  Incidental appendectomy is a safe procedure and can be integrated in surgery for colorectal carcinoma to avoid future complications. Pathological findings of the appendix, including neoplasm, are frequent but clinical relevance remains questionable.

Aim:  Anastomotic leakage is a feared complication of colorectal surgery, and can be devastating in low pelvic anastomosis. With the advent of nonoperative treatments for leakage, the question of management of persistent low colorectal and coloanal anastomosis arises. A review of patients who have undergone transanal repair of anastomotic leakage is presented.

Method:  A review of all anastomoses performed in the Division of Colorectal surgery at two institutions from January 2000 to June 2008 was performed. Anastomotic leakage was defined as the finding at re-operation of a dehiscence or radiographic findings of extravasation from the anastomosis or the identification of intra-abdominal abscess formation at site of the anastomosis, enterocutaneous fistula or rectovaginal fistula. Patients who underwent transanal repair of the leakage were identified.

Results: There were 663 low anterior resections performed during the period. Of these, 36 experienced leakage of a low colorectal or coloanal anastomosis. Of these five patients underwent transanal repair of the anastomotic leak. All had had a low anterior resection for rectal cancer (coloanal=4; low colorectal anastomosis=1). Four had had prior chemoradiation and ileostomy defunctioning at the initial operation. The fifth had an ileostomy created to treat a leak.

Six transanal repairs were performed, including endorectal advancement flap (n=3), dermal flap (n=1), direct suture repair (n=1) and debridement of an infected cavity (n=1). At the time of the present assessment,four patients have undergone reversal of ileostomy after radiographic evidence of complete healing and the fifth patient has a persistent leak.

Conclusion:  Transanal repair of a persistent low colorectal or coloanal anastomotic leakage is feasible in selected cases, even where chemoradiation has been performed.

Aim:  The aim of this prospective study was to evaluate whether the beneficial effect of haemohhoidal artery ligation/transanal haemorrhoidal dearterialisation (HAL/THD) is attributable to a change in the vascular anatomy at the level of the corpus cavernosum recti.

Method:  Patients treated by HAL/THD for grade II or III haemorrhoids were scanned by anal coloured Doppler endosonography before treatment and 6 weeks post-operatively. As a part of a randomized controlled trial (HEMARTY) patients were either treated with or without the Doppler. The number and diameter of vascular structures were measured at the distal, mid and proximal levels in the anal canal.

Results:  There were 30 patients in the non-Doppler and 34 in the Doppler group. The post-operative measurements of the anal coloured Doppler endosonography did not show any significant differences in the vascular anatomy compared to the pre-operative measurement, independent of whether the Doppler probe was used (p>0.05).

Conclusion:  This study failed to show that the effect of HAL/THD is due to alteration of the macroscopic vascular anatomy in the corpus cavernosum recti.

Aim:  Extralevator abdominoperineal excision (APE) for low rectal tumours has been introduced to achieve improved local radicality. Fewer positive margins and intraoperative perforations have been reported compared with standard APE. The aim of this retrospective study was to compare short-term complications and results of the two techniques in our institution.

Method:  Consecutive patients with rectal cancer undergoing abdominoperineal excision between 2004 and 2009 were included. They were divided into two group of 79 patients in extralevator and standard APE. Patients with recurrence and those having a palliative procedure were excluded. Data were collected from hospital records and the colorectal cancer registry. Main endpointgs were wound infection, perineal wound revision, oncologic data and length of hospital stay.

Results:  CRM positivity did not differ significantly between groups (17%extralevator; 20% standard APE). Intraoperative perforation (13 vs. 10%) or local recurrence (7 in each group) were no different. Perineal wound infection was more common after extralevator APE (46 vs. 28%,p<0.05) as was perineal wound revision (22 vs.8% p<0.05). Hospital stay was longer after extralevator APE (median 12 vs. 11 days,p<0.05). Tumour height (median 4 cm) and pTNM-classification did not differ.

Conclusion:  The results do not show any advantage for extralevator APE. The oncologic data were no better and postoperative morbidity was increased. Further studies are needed before extralevator APE is widely adopted in clinical practice.

Aim:  Splenic flexure mobilization (SFM) is standard practice in anterior resections. No previous studies have compared outcomes with and without SFM in laparoscopic and open colorectal cancer surgery. This study aimed to determine whether routine or selective SFM should be advised.

Method:  Data were collected prospectively on all elective anterior resections for cancer in our unit between October 2006 and November 2009.

Results:  Of 263 resections, SFM data were recorded in 216. 138 were laparoscopic (32% with SFM, 3.6% converted) and 78 open (68% with SFM). 88 were low anterior resections (LAR) for mid-low rectal cancers, with 54 laparoscopic (50% with SFM) and 34 open (91% with SFM). Comparing laparoscopic with SFM to without, differences were found in the proportion of LAR (61% vs 29%, p<0.001), defunctioning ileostomy rates (75% vs 46%, p=0.001), and operative time (median 255 vs 185 minutes, p<0.001), with no differences in age, gender, BMI, ASA, preoperative treatment, length of stay, lymph node yield, conversion rate, mortality, anastomotic leakage, reoperation, readmission and R0 resection. No differences in outcomes were seen between laparoscopic LAR with and without SFM, or between open resections with and without SFM.

Conclusions:  Our results show no disadvantage in short-term clinical or oncological outcomes when SFM was avoided. Laparoscopic anterior resections with SFM take longer. A selective approach to SFM is safe during anterior resection (open or laparoscopic), including mid-low rectal cancers.

Aim:  Inflammation occurs in diverticular disease (DD), but there is little information on inflammatory cytokines such as tumour necrosis factor-α (TNF-α). The aim of this study was to assess TNF-α expression in DD and to see whether it is related to the severity of the disease.

Method:  Twenty four patients with symptomatic DD were divided into those with acute uncomplicated diverticulitis [AUD], (12 patients) and symptomatic uncomplicated diverticular disease [SUDD] (12 patients). Twelve further patients with asymptomatic diverticulosis (AD), six with segmental colitis associated with diverticulosis (SCAD), with ulcerative colitis (UC) and six healthy individuals (HC) served as controls. TNF-α expression in the colonic mucosa was assessed by the amount of the mRNA codifying for the synthesis of TNF-α.

Results:  TNF-α expression was significantly higher in AUD than in HC (p=0.0007), in AD (p=0.0001) and in SUDD (p=0.0179). It was significantly higher also in SUDD than in HC (p=0.0007) and in AD (p=0.0001). TNF-α expression in AUD did not differ significantly from that of UC (p=0.0678) and SCAD (p=0.0610). It was significantly higher in UC, SCAD, and AUD than SUDD (p=0.0007, p=0.0001, p=0.0179).

Conclusion:  TNF-α expression in DD seems to be related to the severity of the disease. In particular, it appears to be overexpressed in DD with inflammation (AUD and SUDD) compared with DD without (AD).

Background:  Aberrant crypt foci (ACF) are clusters of colonic crypts that can be identified after staining and have a different behaviour than the surrounding crypts. They have been hypothesized to be the potential precursors of colonic neoplastic lesions. Since they are detectable in vivo with endoscopic stains, they have been proposed as early biomarkers for colonic carcinogenesis.

Aim:  To examine the literature regarding the role of ACF in the pathogenesis of colorectal cancer (CRC).

Methods:  An intensive PubMed search was performed with the following terms: aberrant crypt foci, colorectal cancer, biomarker, carcinogenesis.

Results:  ACF have a variable prevalence and little is known about their natural history. They can be classified as hyperplastic or dysplastic type. There is evidence that supports their role as preneoplastic lesions and features detectable by chromoendoscopy have been related to CRC risk. Moreover, ACF have been shown to harbour genetic and epigenetic alterations common in adenomas and CRC. However, contradictory results have been obtained and difficulties in endoscopic detection and characterization have been described in large scale studies.

Conclusion:  Despite the inconsistencies on ACF detection and characterization, several genetic and epigenetic changes common in both ACF and CRC have been verified throughout the studies. This evidence is increasingly strong and it grows along with the progress in the knowledge of carcinogenesis molecular pathways. Clinical application of ACF as an intermediate endpoint for colorectal carcinogenesis is under development and a deeper knowledge of cancer mechanisms is needed before it can be applied or discarded.

Introduction:  The role of laparoscopic surgery in the management of patients with diverticular disease is still not universally accepted. The aim of our study was to evaluate the results of laparoscopic surgery for diverticular disease in a centre with a specialist interest in minimally invasive surgery.

Methods:  All diverticular resections carried out between 2006 and 2010 were reviewed. Data recorded included baseline demographics, indication for surgery, operative details, length of hospital stay and complications. Complicated diverticular disease was defined as diverticulitis with associated abscess, phlegmon, fistula, stricture, obstruction, bleeding or perforation .

Results:  One hundred and two patients (58 male) who had surgery for diverticular disease were identified (median age 59 years (range 49-70 years). Sixty-four patients (64%) had surgery for complicated diverticular disease. The indications were recurrent acute diverticulitis (37%), colovesical fistula (21%), stricture formation (17%) and colonic perforation (16%). Sixty-nine cases (88%) were completed electively laparoscopically. Post-operative mortality was 0%. For elective cases there was no difference in morbidity rates between patients with complicated and uncomplicated diverticular disease. The overall anastomotic leak rate was 1% and the wound infection rate 7%. There was a non-significant trend to higher conversion to open surgery in the elective group in complicated (11.4%) compared to uncomplicated patients (5.2%) (p=0.67). Electively the rate of stoma formation was higher in the complicated (31.6%) than the uncomplicated group (5.2%) (p<0.02).

Conclusion:  Laparoscopic surgery for both complicated and uncomplicated diverticular disease is associated with low rates of postoperative morbidity and relatively low conversion rates. Laparoscopic surgery is now the standard of care for complicated and uncomplicated diverticular disease in our institution.

Background:  Evidence suggests that follow up after colorectal cancer improves survival. Colorectal cancer is so common that patient follow up can overwhelm a service impacting on the ability to see new referrals and reassess patients seen previously who have new symptoms. In order to cope with this demand a nurse led follow up service was started in 2004. We aimed to review the results of a nurse led colorectal cancer follow up clinic.

Methods:  Between December 1^st 2004 and January 31^st December 2011, patients who underwent resection for colorectal cancer were followed up by a nurse specialist according to a protocol determined by the colorectal surgeons in the unit. All patient details were recorded prospectively in a purpose designed database.

Results:  Nine hundred and fifty patients were followed up over 7 years. Some 368 patients were discharged from the follow up programme, 474 patients remain actively involved in the programme and 108 patients died. Of the patients discharged from the follow up scheme 269 (73%) were discharged to their General Practitioner free of disease after 5 years. Of the 108 who patients died, 98 were as a result of colorectal cancer. Twenty patients (2.1%) were identified with local (peri-anastomotic) disease recurrence and 93 patients (9.8%) were found to have developed distant metastatic disease. Of these, 65 patients (6.8%) were referred for palliative care and 28 (2.9%) had surgery for focal metastatic disease of which 18 were still alive at the time of this analysis.

Conclusion:  This paper shows that a nurse led clinic for colorectal cancer follow up can achieve satisfactory results with detection rates of recurrent or metastatic disease comparable to consultant follow up. A nurse led clinic provides the benefits of follow-up without overwhelming the consultant colorectal surgical clinic practice.

Aim:  The use of laparoscopic colonic surgery in Denmark with particular reference to the length of stay was analysed.

Method:  Data were obtained from the Danish National Patient Registry to assess duration of hospital stay after laparoscopic colonic surgery in Denmark within the 11-year period from 2000-2010.

Results:  There were 4582 laparoscopic colonic resections were performed reaching about 1000 operations/year in the last two years. Length of stay decreased from a median of 7 days to 4 days, while mean length of stay only decreased from 9 to 7 days.

Conclusion:  The use of laparoscopic colonic resection has increased in Denmark over the last 11 years and with a concomitant decrease in postoperative length of stay. However, there is a need for further improvements by combining the laparoscopic technique with fast-track recovery.

Aim:  There is growing evidence that laparoscopic ventral rectopexy (LVR) is an effective treatment for pelvic organ prolapse and obstructive defaecation caused by rectocele. LVR is usually performed using synthetic mesh despite concerns about mesh erosion. We present our experience of using a porcine dermal collagen mesh (Permacol^TM) for LVR, which is the largest such case series to date.

Method:  Data on 65 patients were collected prospectively from May 2008 to October 2010. Outcome measures were complications, recurrence, length of hospital stay, patient satisfaction, Wexner constipation and incontinence scores. Pre- and post-operative scores were compared using the 2-tailed Wilcoxon signed rank test. P < 0.05 was considered statistically significant.

Results:  There were statistically significant improvements in the Wexner constipation scores at 6 months and 1 year (both P < 0.0001) and faecal incontinence scores at 6 months (P < 0.0001) and 1 year (P = 0.0002). There were no cases of mesh erosion or mesh-related infection in our series. Recurrence of symptoms occurred in 2 patients (3.1%). Symptoms were rated as much better or better by 93% at 6 months and this was sustained at one year (96%).

Conclusion:  In the short term LVR using biologic mesh was safe and as effective as synthetic mesh with high patient satisfaction. Constipation and faecal incontinence scores were both improved.

Aim: Biallelic MUTYH germline mutations predispose to recessively inherited adenomatous polyposis, designated MUTYH-associated polyposis (MAP), and colorectal cancer (CRC). The hotspot mutations p.Y179C and p.G396D account for the majority of pathogenic variants in Caucasians. Our aim was to evaluate the prevalence of MUTYH mutations in clinical routine patients with different colorectal diseases.

Method: The hotspot mutations p.Y179C and p.G396D were genotyped in 352 consecutive patients undergoing colonoscopy at our tertiary referral centre. Exons 2-14 were sequenced in hotspot mutation carriers to exclude additional variants.

Results: Overall we identified five heterozygous p.Y179C mutations and three heterozygous p.G396D mutations in seven hotspot mutation carriers (risk allele frequencies 0.7% and 0.4%). Two of these hotspot mutation carriers harboured a heterozygous p.Q338H variant, which is of uncertain clinical significance, on the other allele. Overall, three individuals were biallelic MUTYH variant carriers (p.Y179C/p.G382D: typical MAP; p.Y179C/p.Q338H: atypical MAP with late onset and lower polyp burden; p.G382D/p.Q338H: inflammatory bowel disease), and four subjects were monoallelic mutation carriers.

Conclusions:MUTYH-associated disease, and hence genetic counselling and MUTYH genetic testing, should be considered in the clinical routine of an endoscopy unit, but the wide range of phenotypes represents a challenge for patient identification. The clinical significance of p.Q338H should be evaluated in future case-control studies, since compound heterozygotes for pathogenic mutations and p.Q338H may be at increased risk for mild polyposis or CRC. In addition MUTYH should be assessed as a potential susceptibility gene for the development of colitis-associated CRC in future.

Aim:  ABCB1/MDR1 is found in high concentrations on the apical surfaces of colonic epithelial cells. It acts as an efflux pump by transporting toxic endogenous substances, drugs and xenobiotics out of cells. ABCB1/MDR1 polymorphisms may either change its protein expression or alter its function, suggesting a possible association between ABCB1/MDR1 single nucleotide polymorphisms (SNP) and colorectal cancer. Several studies have reported the relationship between ABCB1 gene polymorphism and colorectal cancer (CRC) risk, but no consistent conclusion has been arrived at. We therefore conducted a meta-analysis to identify any association between ABCB1 gene and CRC risk.

Method:  PubMed, Embase, Google Scholar, Cbmdisc and CNKI were searched for studies on the relationship of ABCB1/MDR1 SNPs and the incidence of CRC. Eligible articles were included for data extraction. The main outcome was the frequency of ABCB1/MDR1 SNPs among cases and controls. Comparison of the distribution of SNP was mainly performed using Review Manager 5.0.

Results:  There were ten, four and two trials focusing on ABCB1 rs1045642, rs2032582 and rs3789243 SNP respectively. A total of 3175 cases and 3715 controls were included. The meta-analysis, stratified by ethnicity or population source, indicated no association between ABCB1 rs1045642 polymorphism and CRC risk. However, when the study by Bae et al was removed from the analysis, there was some evidence to indicate a higher frequency of T allele in CRC patients among Asians (OR= 1.30, 95%CI 1.02-1.67,P=0.03). Neither ABCB1 rs2032582 nor rs3789243 indicated an association with CRC risk. An increased frequency of only wild-type combined allele (rs2032582G/ rs1045642C) was found in Caucasian patients (OR= 1.22, 95%CI 1.03-1.44, P=0.02).

Conclusion:  There is some evidence to indicate an association of ABCB1 rs1045642T and CRC risk in Asians. Compared with SNPs for ABCB1 rs1045642, rs2032582 or rs3789243 alone, combined haplotypes of several SNPs might be a better marker to determine the genetic influence on the susceptibility to CRC among Caucasians.

Aim:  Following introduction of 2 week-wait (2ww) cancer pathway many units are triaging patients with change in bowel habit (CIBH) and/or rectal bleeding (RB) straight to colonoscopy. Evidence suggests that right-sided colonic cancer does not present with these symptoms, hence imaging the left colon only is satisfactory. If this were substantiated, patients could be offered a flexible sigmoidoscopy (FS) alone. This study aimed to review presenting symptoms of patients diagnosed with a right-sided colonic malignancy and assess whether their tumours would be missed based on this practice.

Method:  This is a retrospective analysis of patients who underwent curative resection for a proximal colonic malignancy over a 4-year period. 2ww referral proforma and case notes were analysed for mode of presentation.

Results:  Of 206 elective right hemicolectomies performed, 20/206 (9.7%) patients presented in the absence of either iron deficiency anaemia or palpable abdominal mass. 12 patients had polyposis identified in the left colon and 8 patients had no left-sided colonic pathology. 1 patient had a strong family history of colon cancer (2 first degree relatives) in the group absent of left-sided pathology.

Conclusion:  12 patients who had left sided polyposis and one patient with a strong family history would have undergone WCI based on current CRC management guidelines. The remaining seven patients with right-sided cancer would have been missed if FS were the only investigation used. Patients presenting on the 2ww with symptoms of a CIBH and or RB can be adequately investigated with a FS with a 3% chance of missing a proximal cancer.

Aim:  The new TNM classification is currently being implemented. We evaluated the TNM-7 staging system based on the two nationwide colon cancer registries in the United States and Japan to clarify whether this system better stratifies patients’ prognoses than the TNM-6 did and to determine whether stratification can be effectively simplified.

Methods:  The Surveillance, Epidemiology, and End Results population-based data from 1988 to 2001 for 50,139 colon cancer patients and the multi-institutional registry data from the Japanese Society of Cancer of the Colon and Rectum from 1984 to 1994 on 10,754 patients were analyzed. We devised a modified version of the TNM-7 staging system to allow simpler classification of the TN categories and compared the TNM-6, TNM-7, modified TNM-7, and the Dukes’ staging system based on survival curves and objective statistical tests such as likelihood ratio χ² tests, Akaike’s information criterion, and Harrell’s c-index.

Results:  The TNM-7 was superior to the TNM-6 in all objective statistical tests in the United States (c-index; 0.700 vs. 0.696, p<0.001) as well as in the Japan data sets (0.732 vs.0.729, P=0.035). The modified TNM-7 is much simpler, but it nevertheless showed similar values to those of the original TNM-7 (c-index; the United States 0.702, Japan 0.733).

Conclusions:  The new TNM-7 is complicated but better at stratifying patients than the TNM-6 in the United States and Japan, and could be effectively simplified.

Aim:  Altmeier’s procedure (perineal rectosigmoidectomy) is the operation of choice for rectal prolapse in the elderly. The aims of this prospective observational study were to evaluate its long-term actuarial recurrence risk and the influence of the length of rectosigmoid resection and associated levatorplasty on recurrence rate and continence.

Method:  The perioperative and long-term data of all patients undergoing Altemeier’s procedure since 1992 were analyzed with regard to mortality, morbidity, continence, anorectal function and recurrence rate.

Results:  Sixty patients (median age: 77 years [35-98]) underwent rectosigmoid resection (median length of bowel 14 [6-60] cm) with associated levatorplasty in 21 (35%). Overall mortality and morbidity were 1.6% and 11.6% respectively. Manometry showed increased anal sphincter basal pressure and maximal squeeze pressure. We observed a decrease in postoperative rectal compliance (p=0.002). Age, gender, prolapse duration before surgery, levatorplasty and length of resection had no statistically significant relationship to recurrence. Continence improved in 62% and was stable over a median follow-up of 48 [1-186] months). Continence was positively related to a short length of bowel resection, but not to decreased rectal compliance. Actuarial recurrence was 14% at 4 years.

Conclusion:  The long-term recurrence rate after Altemeier procedure was low and not linked to resection length or to levatorplasty. Improvement in continence was stable over time.

Aim:  The effectiveness of rectal washout was compared with no washout for the prevention of local recurrence after anterior rectal resection for rectal cancer.

Method:  The following electronic databases were searched: PubMed, OVID Medline, Cochrane database of systematic reviews, EBM reviews, CINAHL and EMBASE.

Results:  Five non-randomised studies were identified including 5.012 patients were included. Eat-analysis suggested that rectal washout significantly reduced the local recurrence rate (P<0,0001; OR 0.56; 95% CI, 0.43-0.72). It was also significantly lower after washout in patients having radical resection only (P=0.0004, OR 0.54, 95% CI, 0.39-0.76), patients treated with by a curative resection (P<0.001, OR 0.55.95% CI 0.42-0.72) and those undergoing preoperative radiotherapy (P=0.04,OR 0.62, 95% CI 0.39-0.98).

Conclusion:  Taking into account the limitations of the design of the included studies the meta-analysis showed that rectal washout is associated with reduced local recurrence and therefore should be routine during anterior resection for rectal cancer.

Aim:  The study aimed to compare the robotic versus laparoscopic rectal resection for cancer.

Method:  Randomised and non randomised clinical trials comparing robotic and laparoscopic resection for rectal cancer were identified using the following electronic databases: Pub Med, EMBASE, OVID Medline, Cochrane database of systematic reviews, EBM reviews and CINAHL. Twelve end points were identified including intraoperative outcome, early postoperative mortality and morbidity and oncologic parameters. A subgroup analysis of patients undergoing full-robotic (FR) or robot-assisted (RA) rectal resection and robotic total mesorectal excision (RTME) was carried out.

Results:  There were eight non-randomised studies, including 854 patients, with 344 (40.2%) in the robotic and 510 (59.7%) in the laparoscopic group. Meta-analysis suggested that the conversion rate to open surgery in the robotic group was significantly less than with laparoscopic surgery (OR of 0.26, 95% CI: 0.12 to 0.57, P = 0.0007). There were no significant differences in operation time (WMD of 19.79, 95% CI: -11.01 to 50.58, P = 0.21), intraoperative blood loss, postoperative morbidity and mortality and the oncological accuracy of resection.

Conclusion:  Robotic surgery for rectal cancer has a lower conversion rate and similar operative time compared with laparoscopic surgery, with no difference in recovery, oncologic and post-operative outcome.

Aim:  Percutaneous tibial nerve stimulation (PTNS) is increasingly used as a treatment for faecal incontinence (FI). The evidence for its efficacy is limited to a few studies involving small numbers of patients. The aim of the study was to assess the efficacy of PTNS in patients with urge, passive and mixed incontinence.

Method:  A prospective cohort of 100 patients with FI was studied. Continence scores were determined before treatment and following 12 sessions of PTNS using a validated questionnaire (Cleveland Clinic Florida-FI score). The deferment time and average number of weekly incontinence episodes before and after 12 sessions of treatment were estimated from a bowel dairy kept by the patient. Quality of life was assessed prior to and on completion of 12 sessions of PTNS using a validated questionnaire (Rockwood Faecal Incontinence QoL).

Results:  100 patients (88 female) of median age of 57 years were included. Patients with urge incontinence (n=25) and mixed incontinence (n=60) demonstrated a statistically significant improvement in the mean CCF-FI score (11.0±4.1 to 8.3±4.8 and 12.8±3.7 to 9.1±4.4) with an associated improvement in the QoL score. This effect was not observed in patients with purely passive FI (n=15).

Conclusion:  The study demonstrates that PTNS benefits patients with urge and mixed faecal incontinence at least in the short term.

Aim:  Surgical closure of high or complex anal fistulas often is a difficult challenge. A special Nitinol clip, the OTSC-clip (Ovesco AG, Tuebingen, Germany), was evaluated for fistula closure in a porcine model.

Method:  A total of 20 fistulas were created in 10 animals by seton insertion. Four weeks after fistula induction the setons were removed: one internal fistula opening per animal was left untreated as control whereas the other opening was closed by the OTSC-clip using a specially developed transanal clip-applicator. The safety and technical feasibility of the clip application was tested. Another four weeks later, fistulas were macroscopically assessed for closure. For histologic examination, the anorectum including the fistula tract was excised en bloc.

Results:  Four weeks after clip placement, all external and internal fistula openings were macroscopically closed. The clip application site presented with an increased scarring. Microscopically, 40% residual tracts and a more intense chronic inflammation were seen in the untreated control fistulas. After clip placement, 10% of the fistulas persisted associated with a higher density of collagen fibers indicating a better fistula scarring and healing. No unexpected side effects or complications caused by the clip were observed.

Conclusions:  Fistula closure using the OTSC-clip represents a promising sphincter-preserving minimally invasive procedure. This study demonstrated the safety and feasibility of the ‘anal fistula claw’ for fistula closure. In spite of limitations of the porcine model the results justify clinical applications and further investigations.

Background:  Studies of skeletal muscle show that fatigue fate corresponds to the proportion of fast-twitch and slow-twitch fibres that are present in the muscle. Limited work has been done on the fatigue rate of the external anal sphincter. We have prospectively studied fatigability of the external anal sphincter in women with faecal incontinence and women with normal bowel control.

Methods:  Anorectal manometry was measured by a station-pull technique using a water-filled microballoon. Fatigue rate was calculated from anal pressure measurements taken every 0.1seconds over a 20-second squeeze.

Results:  Women with faecal incontinence (n=88, median= -12cmH₂O/min) were less susceptible to fatigue than women with normal bowel control (n=36, median= –43cmH₂O/min), (p<0.01).

The external anal sphincter was less susceptible to fatigue with increasing age (p<0.01, r=0.499). In women with normal bowel control and in women with faecal incontinence fatigue rate negatively correlated with Maximum Squeeze Pressure (p<0.01, r= -0.287; p<0.01, r= -0.579).

Conclusions:  The external anal sphincter was less susceptible to fatigue with increasing age. Women with faecal incontinence have a weaker but more fatigue resistant external anal sphincter. This might correspond to a higher proportion of slow-twitch muscle fibres. Histological studies are needed to examine this hypothesis.

Aim:  Guaiac-based faecal occult blood tests (gFOBT) are used in the colorectal cancer screening programme. Recent data suggested the immunological faecal occult blood test (iFOBT) illustrated a variation in positivity according to season and ambient temperature. Our aim was to assess the effect of season and ambient temperature on the positivity rates of guaiac faecal occult blood tests during pilot screening for colorectal cancer.

Methods:  Data from the first year of round 1 of the pilot screening programme in Coventry and Warwickshire were analysed. Patients with positive and negative FOBT samples were included. Patients with spoilt samples or incomplete data were excluded. A total of 58 513 patients were included. There were 30 311 males and 29 202 females. Mean age was 56 years. Daily temperature data were provided by the meteorological office.

Results:  Median exposure of the FOBT test card was 6 days (range 1-17). Median daily maximum temperature was 14°C. Spring and summer illustrated significantly decreased positivity rates compared with autumn and winter (Pearson’s chi-squared p= <0.001). Mean daily maximum temperature for the test card exposure showed no significant difference in positivity rates (p =0.53). Subgroup analysis revealed a significant reduction in positive samples in the >25° C subgroup (p= 0.045).

Conclusions:  There is a seasonal variation in positivity rates of gFOBT with increased positivity in spring and summer months. There is no difference in positivity rates in relation to ambient temperature except in subgroup analysis where there is a significant reduction in positivity rates above 25°C.

Aim:  Single port laparoscopic colorectal surgery (SPLC) performed through a single incision ≤3cm has been shown to be feasible. This study aimed to assess its safety and efficacy when used as the method of choice for right hemicolectomy.

Method:  A prospective study was carried out of patients undergoing right hemicolectomy using a single port laparoscopic technique. They were compared with a historical series using multiport laparoscopic technique. Between December 2009 and September 2010 single port surgery replaced conventional laparoscopic colorectal surgery (LCS) for radical medial to lateral right hemicolectomy performed by a single surgeon. Histology, length of hospital stay, complications, conversions and readmissions were recorded.

Results:  Fourteen cases were undertaken, 10 for carcinoma (Dukes stage A 1, B 6, C 3) and four for Crohn’s disease. Twelve cases of multiport laparoscopic colorectal surgery (LCS) were undertaken, eight for carcinoma (Dukes stage B 4, C 3, Carcinoid 1), three for Crohn’s disease and one for adenoma. The median operative time for SPLC was 120 (interquartile range 90 – 135) minutes and the median length of hospital stay was 3.5 (interquartile range 2.0 – 5.0) days. The median operative time for LCS was 135 (interquartile range 116 – 150) minutes and the median length of hospital stay was 4.0 (interquartile range 3.8 – 7.0). The median number of lymph nodes removed for SPLC cases was 14.5 (interquartile range 9.8 – 19.5) and for the LCS cases was 14.5 (interquartile range 13.0 – 19.5). There were no conversions, no complications and no readmissions for both groups.

Conclusion:  These data confirms the feasibility of the technique. Furthermore they suggest that it is safe and efficacious.

Aim:  Perforation occurs rarely after colonoscopy, but is associated with a high morbidity and mortality. In this study, we assessed the perforation rate in our hospital, its clinical diagnosis and the long-term outcome.

Method:  During the study period, 7535 examinations were performed, of which 4830 were diagnostic and 2705 therapeutic. The latter included polypectomy, endoscopic mucosal resection, endoscopic submucosal dissection, dilatation and argon plasma coagulation.

Results:  Overall, 25 perforations (0,33%) occurred with two (0.026%) procedure-related deaths., Seven (0.14%) perforations occurred during a diagnostic and 18 (0.67%) during a therapeutic procedure. Dilation,,submusous resection (SMR) and argon plasma coagulation (APC) accounted for more perforations than polypectomy or diagnostic colonoscopy. Pre-existing gastrointestinal disease was present in 24 (96%) of perforations. Three (12%) patients were treated conservatively, and 22 (88%) underwent surgery. The site of perforation was closed by suture in four (18%) and resected with colonic anastomosis in five (23%) patients. Two patients underwent endoscopic clipping. A stoma was created after resection in 13 (59%) patients.

Conclusion:  Death from perforation after colonoscopy is rare occurring in 1/3500 examinations.. The risk is increased in therapeutic colonoscopy and in the presence of previous gastrointestginal disease. Dilatation, SMR and APC appeared to confer higher risk of perforation than polypectomy or diagnostic colonoscopy.

Aim:  Local recurrence is an important endpoint of rectal cancer treatment, but details of this form of treatment failure are less well described. The aim of this study was to acquire deeper knowledge of local recurrence regarding symptoms, diagnostic work-up, clinical management, health-care utilization and outcome.

Method:  Of 671 patients with rectal cancer, 57 were diagnosed with local recurrence within 5 years after surgery. Their records were analysed.

Results:  At diagnosis of local recurrence 49(86%) of 57 patients were symptomatic and 40 (70%) were diagnosed between scheduled follow-up visits. The predominant symptom was pain. Forty five of the 57 (79%) had a palpable tumour. Most were deemed incurable at presentation and less than 10 (18%) were operated on with curative intent. Five years after the initial rectal cancer surgery, two patients were alive, with one free of disease. Despite the need for multiple interventions, including surgery, only 4 out of 40 patients were classified as being well palliated in the terminal stage.

Conclusion:  Follow-up after rectal cancer surgery by annual clinical examination is not sufficient to detect local recurrence when it is asymptomatic. Local recurrence of rectal cancer is often associated with intractable symptoms. These patients require frequent interventions and can rarely be cured if diagnosed at an advanced stage. Strategies for early detection of local recurrence and the management thereof require improvement.

Aim:  Port placement in laparoscopic surgery has important ergonomic implications. A manipulation angle (MA) of 60% has been shown to maximize task efficiency. We calculated the MA used during various stages of both right hemicolectomy (RH) and high anterior resection (AR).

Method:  We compared two methods of port placement (PP) for each operation. RH-PP1 included ports in the left iliac fossa and left upper quadrant. RH-PP2 included ports suprapubically and in the left iliac fossa. We calculated the MA of each of these methods in mobilising both the caecum and hepatic flexure. AR-PP1 included ports in the right iliac fossa and right upper quadrant. AR-PP2 included ports suprapubically and in the right iliac fossa. We calculated the MA of each of these methods in mobilising the splenic flexure, descending-sigmoid junction and the recto-sigmoid junction.

Results:  For RH-PP1, the mean MA for mobilising the caecum and hepatic flexure were 38 and 52 degrees respectively. For RH-PP2, the mean MA for mobilising the caecum and hepatic flexure were 58 and 44 degrees respectively. For AR-PP1, the mean MA for mobilising the splenic flexure, the descending-sigmoid junction and the recto-sigmoid junction were 77, 41 and 18 degrees respectively. For AR-PP2, the mean MA for mobilising the splenic flexure, the descending-sigmoid junction and the recto-sigmoid junction were 40, 56 and 34 degrees respectively.

Conclusion:  There are no two port placements that will allow for an ideal manipulation angle at every stage of mobilisation for either right or left sided resection.

Aim:  The study was conducted in a dedicated centre treating the majority of Danish patients with intended curative total pelvic exenteration (TPE) for primary advanced (PARC) or locally recurrent rectal cancer (LRRC). We compared PARC and LRRC and analysed postoperative morbidity and mortality, and long-term outcome.

Method:  There were 90 consecutive patients (PARC/LRRC: 50/40) treated between January 2001 and October 2010, recorded on a prospectively maintained database.

Results:  The median age was 63 (32-75) years with a gender ratio of 7/83 (F/M). All patients were ASA I or II. Sacral resection was performed in five patients with PARC and 15 with LRRC (p=0.002). R0 resection was achieved in 33 (66%) patients with PARC and in 15 (38%) with LRRC, R1 resection in 17 (34%) with PARC and 20 (50%) with LRRC and R2 resection in five (13%) with LRRC. R0 resection was more frequent in PARC (p=0.007). Forty-four (49%) patients had no postoperative complications. Fifty five major complications were registered. Two (2.2%) patients died within 30 days, and the total in-hospital mortality was 5.6%. The median follow-up was 12 (0.4-91) months. The 5-year survival was 46% for PARC and 17% for LRRC (p=0.16).

Conclusion:  Pelvic exenteration is associated with considerable morbidity but low mortality in an experienced centre. Pelvic exenteration can improve long-term survival, especially for patients with primary advanced rectal cancer. However, pelvic exenteration is also justified for patients with locally recurrent rectal cancer.

In an attempt to improve cancer detection we evaluated the clinical features of invasive CRC detected within 5 years of a negative colonoscopy.

Method:  The details of colonoscopy performed in a rural hospital in Japan were prospectively recorded at the time of the examination. The patients were followed over five years for the subsequent occurrence of cancer.

Results:  In a 5-year period, 10,148 patients underwent colonoscopy and 202 without previous colonoscopy were diagnosed with invasive CRC. Of 3,212 patients with a colonoscopy negative for cancer, nine developed invasive cancer within five years. The ratios for invasive CRC detected without/with previous colonoscopy were 60:1 in the rectum, 54:1 in the sigmoid colon, 15:1 in the descending colon, 28:0 in the transverse colon, 31:5 in the ascending colon, and 14:1 in the caecum (p=0.041). The ratio between left- and right-sided colonic cancer was also significantly different (129:3 and 45:6, p=0.0078). Six (67%) of the invasive CRC were in the ascending colon or caecum. Five of six patients with invasive CRC in the ascending colon and caecum had right-sided small adenomas at prior colonoscopy.

Conclusion:  The majority of early/missed CRC were right-sided and associated with prior right-sided colonic adenomas. Repeated colonoscopy of patients with right-sided adenomas at a shorter surveillance interval deserves consideration.

Aim:  Gentamicin-impregnated collagen (Collatamp®) is well described for the prevention of infection in surgery..This technical note describes its intraoperative use as a prophylactic measure to prevent infection following implantation of a sacral nerve stimulator for faecal incontinence.

Method:  Following implantation of the Interstim II Neurostimulator (Medtronic Neuromodulation, 710 Medtronic Parkway, Minneapolis, USA) in a subcutaneous pocket overlying the gluteal muscle, a single sheet of 10cm x 10cm gentamicin-impregnated collagen is placed within the wound covering the implant. The subcutaneous tissue and skin are then closed in separate layers.

Results:  To date eight patients (median age 46.5 (30-59) years) received prophylactic cover with Gentamicin-impregnated collagen following permanent sacral nerve stimulator implantion. At a median interval of 89.5 (51-128) days), none of these patients developed a wound infection at the site of the neurostimulator implant.

Conclusion:  Gentamicin-impregnated collagen (Collatamp®) used in the implantation of a sacral nerve stimulator may be a useful addition to the technique.

Aim:  Assessment of procedural colonoscopy skills is an important and topical. The aim of this study was to develop and validate a competency-based colonoscopy assessment form that would be easy to use, suitable for the assessment of junior and senior endoscopists and potentially be a useful instrument to detect differences in performance standards following different training interventions.

Method:  A standardised assessment form was developed incorporating a checklist with dichotomous yes/no responses and a global assessment section incorporating several different elements. This form was used prospectively to evaluate colonoscopy cases during the period of the study in several university teaching hospitals. Results were analysed using ANOVA with Bonferroni corrections for post-hoc analysis.

Results:  81 procedures were assessed, performed by eight consultant and 19 trainee endoscopists. There were no serious errors. When divided into three groups based on previous experience (novice, intermediate and expert) the assessment form demonstrated statistically significant differences between all three groups (p<0.05). When separate elements were taken into account, the global assessment section was a better discriminator of skill level than the checklist.

Conclusion:  This form is a valid, easy to use assessment method. We intend to use it to assess the value of simulator training in trainee endoscopists. It also has the potential to be a useful training tool when feedback is given to the trainee.

Aim:  Abdominoperineal excision of the rectum (APER) for cancer has been associated with higher circumferential resection margin (CRM) involvement and failure of local disease control. The aim of this study was to investigate whether the introduction of laparoscopic APER compromised altered the incidencse of CRM involvement.

Method:  Consecutive patients undergoing open or laparoscopic APER for adenocarcinomas of the rectum were studied. Patient demographics, pre-operative staging, neo-adjuvant treatment, operative findings, length of stay and pathological details were collected from operative and radiology databases and compared.

Results:  There were 16 laparoscopic and 25 open APER performed over a three year period Neo-adjuvant therapy was given to 43.8% (7/16) of the laparoscopic group and 56.0% (14/25) of the open group. Complete laparoscopic resection was possible in 14 (87.5%) of 16 patients. The median harvested number of nodes was 14 (4-33) in both groups. The median LOS was 7 (3-13) and 15 (9-40) days in the laparoscopic and open groups (p<0.001). The CRM was clear in all cases. There was no local recurrence in either group at a median follow up of 23 months. There were no in hospital deaths and no significant differences in overall survival. There were no significant differences in pre-operative or post-operative histopathological T-stage between the two groups (p=0.057 and p=0.121).

Conclusion:  Laparoscopic APER for selected rectal cancers can achieve comparable oncological outcome to open surgery but is associated with a much shorter length of stay. Patient and tumour characteristics must be taken into consideration when deciding on a laparoscopic approach for low rectal cancer.

Aim:  Present quality of life (QoL) instruments for inflammatory bowel disease (IBD) do not evaluate many social aspects of patients’ lives that are potentially important in clinical decision making. We have developed a new Social Impact of Chronic Conditions - IBD questionnaire (SICC-IBD) to assess these areas.

Method:  A 34-item questionnaire was piloted to determine quality of life relating to education, personal relationships, employment, independence and finance. It was compared with the SF-36v2 and Inflammatory Bowel Disease (IBDQ) questionnaires in 150 patients with chronic ulcerative colitis on an endoscopic surveillance register who had never had surgery.

Results:  Reliability and validity testing enabled the questionnaire to be shortened to only 8 items. There was a high level of reliability (Cronbach’s alpha = 0.72). The questionnaire correlated well with the social functioning domain of the SF-36 (r_s=0.56) and was able to distinguish clinical severity of disease.

Conclusion:  The SICC-IBD is a new tool for assessment of patients with ulcerative colitis, which has identified new aspects of social disability for further study and for potential use as an additional tool in therapy decisions.

Aim:  Patients with lung metastasis from colorectal cancer may benefit from surgical resection. Chest computerised tomography (CT) is often included in the preoperative staging. Interpretation of the nature of pulmonary lesions is not always easy and may question its clinical value.

Method:  Clinical data of all patients treated at our institution for colorectal cancer (CRC) have been collected prospectively in a dedicated database. Since August 2008 chest CT has been routinely performed for preoperative staging. The outcome of 147 patients operated since then (Group A) was compared with a numerically equal group of patients (147) (Group B) treated before the introduction of preoperative routine Chest CT.

Results: Pulmonary lesions were identified in 45 (30%) patients in Group A and 10 (6.8%) in Group B. Ten and 9 lesions respectively were interpreted as metastases. In 28 (19%) patients in Group A, the lesions were considered to be indeterminate and only four were confirmed as malignant. Overall metastases were present after one year of follow-up in 5 (50%) of 10 patients in Group A and 5 (55%) of 9 in Group B. The global incidence of synchronous and metachronous metastases was 6.8% with no statistical difference between the two groups.

Conclusion:  The study shows that chest CT reveals a higher number of pulmonary lesions only a small proportion of which were malignant. The investigation does not add value to routine staging methods in patients with CRC.

Aim:  The incidence and mortality of colorectal cancer (CRC) were quantified in persons with and without diabetes mellitus (DM).

Method:  MEDLINE and EMBASE were searched for articles published before July 2010. Cohort studies that evaluated DM and CRC incidence and mortality were included. The initial search identified 1887 titles, of which 24 articles met the inclusion criteria. We defined the relative risk (RR) as the metric of choice, with 95% confidence intervals (CIs) were calculated with a random-effects model.

Results:  There was an increase in the RR of developing colorectal cancer in persons with diabetes compared with those without diabetes (RR 1.28 [95%CI 1.19 - 1.39]), without heterogeneity between studies (P_{heterogeneity} = .13). The association between duration of DM and CRC incidence was stronger in 11–15 yr group (RR 1.51 [95%CI 1.12 - 2.03]) than in < 10 yr (RR 1.05 [95%CI 0.90 - 1.22]) and >15 yr group (RR 1.25 [95%CI 0.80 - 1.94]), and there was significant heterogeneity among subgroups (P_{heterogeneity} = .01). In studies reporting standardized incidence ratios (SIR), there was an increased incidence of CRC with DM (RR 1.27 [95%CI 1.14 - 1.42] P_{heterogeneity} = .09); and the association was stronger among males (RR 1.47 [95%CI 1.15 - 1.86]) than females (RR 1.08 [95%CI 1.00 - 1.17]), there was significant heterogeneity among gender (P_{heterogeneity} = .01).

Conclusion:  This meta-analysis suggests diabetic individuals have a significant increase in risk of developing colorectal cancer.

Aim:  The aim of this study was to evaluate long-term functional outcome of ileal pouch-anal anastomosis for ulcerative colitis and to compare symptoms over time.

Methods:  188 patients were operated with an ileal pouch-anal anastomosis. Short-term functional outcome has previously been evaluated with a symptom questionnaire. The same questionnaire was sent to the 162 patients who were alive and had an intact pouch. A symptom index was studied over time and in relation to early complications and pouchitis.

Results:  The response rate of the questionnaire was 139/162 at a median of 12.5 (9.5-21) years postoperatively. Overall, the symptom index remained unchanged over time but both the frequency of night-time defecation and episodes of night time incontinence increased. Patients’ global assessment was unchanged with approximately 80 per cent stating an excellent or a good result. Frequency of pouchitis doubled in ten years. Symptom index for patients with episodic pouchitis (median 40 (8-89), p=0.018) and recurrent/chronic pouchitis (71 (8-136), p<0.001) was higher than in patients without pouchitis (29 (0-105). Early complications did not affect the symptom index.

Conclusion:  The overall functional outcome of ileal pouch-anal surgery for ulcerative colitis is stable over time. Patients’ satisfaction with outcome remains high. Pouchitis is a determinant of functional outcome.

Aim:  The long-term results of stapled haemorrhoidopexy for prolapsed haemorrhoids were assessed using uniform methods to acquire data and pre-set definitions of failure, recurrence, residual symptoms, and impaired continence.

Method:  From October 1999 to May 2005, 153 patients underwent a stapled haemorrhoidopexy and were enrolled prospectively. They were assessed preoperatively, postoperatively and at the end of the study from replies to a questionnaire about symptoms and continence. Preoperatively, manual reduction of prolapse was required in 103 patients, and skin tags were found in 115 patients (circumferential in 22) and impaired continence in 63.

Results:  145 patients completed preoperative and long-term protocols and were analyzed as paired data, at a mean follow-up of 32 months. Failure to control the prolapse or recurrence was seen in 19 (13%) patients including nine re-operations for prolapse. Symptoms improved from 8.1 to 2.5 points on a 15-point scale (P=0.001). Symptoms were not controlled in 25 (17%) patients. Continence improved from 4.7 to 2.9 points on a 15-point scale (P=0.001). Twenty-five (17%) patients still had a continence disturbance. Altogether 51 (35%) patients had a deficient outcome with respect to prolapse, symptoms or continence. There were no major adverse events.

Conclusion:  Restoration of the anal anatomy by stapled haemorrhoidopexy resulted in a significant improvement in haemorrhoid-associated symptoms and continence but a third of patients had poor symptom control including 13 percent with persisting prolapse.

Aim:  Colonoscopic high frequency mini probe ultrasound (HFUS) was compared prospectively with computed tomography in the local staging of colonic cancer.

Method:  Consecutive patients undergoing surgical resection for colonic cancer were recruited. Pre-operative 64-slice computerized tomography (CT) staging with multiplanar reconstruction was compared with colonoscopic HFUS using 12.5 MHz and 20 MHz US probes. The three methods of staging (CT, US 12.5 MHz and US 20 MHz) were compared with the histological stage of the resected specimen. This was done using weighted kappa coefficients where weights of 0.7 to 0.8 were given to penalize disagreements of one level in either direction and weights of zero were given to penalize disagreements of more than one level in any direction.

Results:  38 patients with colonic cancer were included. They were located in the sigmoid (n=20),, descending (n=5), ascending (n=2) and transverse colon (n=1) and in the caecum (n=7) and splenic (n=2), and hepatic flexure (n=1). Histopathological assessment revealed 7 pT1, 4 pT2, 25 pT3 and 2 pT4 cancers. In relation to the pathology the weighted Kappa coefficients were 0.36 (SE=0.14), 0.81 (SE=0.16) and 0.81 (SE=0.17) for CT, ultrasound 12 MHz and ultrasound 20 MHz.

Histopathologically 15(39.5%) patients were lymph node positive. The sensitivity and specificity and kappa coefficient for detection of nodal disease for CT were 80%, 47.8% and 0.25 (SE=0.14). compared with 80%, 82.5 and 0.62 for 12 MHz US (SD=0.14) and 23%, 90.5% and 0.15(SD=0.13) for MHz 20 ultrasound..

Conclusion:  Colonoscopic ultrasound is significantly more accurate than CT for T staging of colonic cancers. With respect to nodal status, 12 MHz US offer superior accuracy than CT or 20 MHz US.

Aim:  A systematic review was performed to identify differences in surgical technique, postoperative morbidity and length of hospital stay and safety for procedures involving left-sided laparoscopic colectomy with natural orifice specimen extraction.

Method:  A Pubmed search was performed to retrieve studies reporting on left-sided laparoscopic colorectal resection with transrectal specimen extraction. The quality of the different reports was assessed according to the Newcastle-Ottawa scale. Six studies were included and all but one were cohort studies. Studies on transanal, transvaginal or transcolonic specimen extraction were excluded, as were reports on paediatric surgery.

Results:  Six articles (including 94 patients) fulfilled the search criteria. The techniques reported were not standardised and this technical heterogeneity hampered pooled analysis. A meta-analysis could also not be performed because of differences in inter-study methods, study population, and results. All studies showed, nevertheless, that the technique is feasible with low morbidity and postoperative hospital stay. No anal dysfunction was reported.

Conclusion:  To date, the evidence in favour of left-sided laparoscopic colectomy with transrectal specimen extraction is weak (level IV-V). Future clinical research should focus on standardization of the technique. Randomized controlled trials are necessary to show the superiority of this approach with regard to postoperative pain and morbidity, hospital stay, recovery, function and cosmesis.

We report a case of a rectovesical fistula secondary to diffuse large B-cell lymphoma (DLBCL) of the rectum; a previously unreported occurrence.

Aim:  Large (>2cm) rectal adenomas are currently treated by transanal endoscopic microsurgery (TEM) or piecemeal endoscopic mucosal resection (EMR). The potential lower morbidity of EMR becomes irrelevant if EMR is less effective. We aimed to compare the safety and effectiveness of EMR and TEM for large rectal adenomas.

Method:  Data from patients undergoing TEM or EMR for a rectal adenoma >2cm in eight hospitals were retrospectively collected. Patient and procedure-related characteristics, complications and recurrences were recorded. As EMR may require several attempts to achieve complete resection, early (after single intervention) and late (permitting retreatment for residual adenoma within 6 months) recurrence rates were determined.

Results:  292 patients (49% males; mean age 67 years) were included; 219 were treated by TEM and 73 by EMR. Adenomas treated by EMR were smaller (median 30 vs. 40mm; P=.007). Perioperative complication rates were 2% for TEM and 6% for EMR (p=.171). Postoperative complications occurred in 24% of TEM patients and in 13% of EMR patients (P=.038). Median hospitalization after TEM was 3 days vs. 0 days after EMR (P<0.001). Median follow-up was 12.6 months (0-47); Early recurrence rates were 10.2% in TEM patients and 31.0% in EMR patients (P<0.001); late recurrence rates were 9.6% and 13.8% (P=.386).

Conclusion:  After single intervention, EMR of large rectal adenomas seems less effective, but safer than TEM. When allowing retreatment of residual adenoma within 6 months, EMR and TEM seem equally effective. A prospective randomized comparison seems necessary.

Aim:  The study aimed to define the mortality in the elderly following elective colorectal resection and to identify the most meaningful postoperative period to report mortality rates in this group of patients.

Method:  A systematic review was undertaken to identify studies that reported on mortality in the elderly following elective colorectal resection. MEDLINE, EMBASE and PUBMED searches were carried out by two independent reviewers and results were collated. Two reviewers conducted literature searches independently and the third reviewer acted as an arbiter in case of discordance.

Results:  236 studies published in the year 2000 or later were identified in the search,. Those that included emergency surgery, patients operated prior to 1995 or did not comment on mortality in an elderly age group were excluded. Seventeen studies were finally included in the review. 30-day or post-operative mortality rates varied from 0% to 13.3%. Short term mortality was low in elderly patients selected for minimal access surgery. National population and registry observational audits reported higher short term mortality rates than most small case series or cohort studies. One national audit demonstrated that a significant mortality risk persists up to one year after surgery.

Conclusion:  Historical case series suggest that 30-day mortality following colorectal resection in the elderly is low. The reliability of 30-day mortality measures to reflect surgical success in this cohort is, however, questionable as a significant proportion of patients die in the months that follow surgery.

Introduction:  Although there are numerous studies on the efficacy of enhanced recovery after surgery (ERAS) protocols in reducing length of stay – the long-term compliance to such protocols in routine clinical practice has not been well documented. The aim of this study was to review the published literature on compliance to ERAS in patients undergoing colorectal surgery in routine clinical practice.

Methods:  An analysis of studies which focused on the compliance to ERAS protocols during routine clinical practice were identified from Medline, Embase and PubMed databases. Fourteen studies fulfilled the inclusion criteria and a total of 19 perioperative ERAS modalities were identified across these studies.

Results:  None of the studies used all the 19 modalities within their ERAS protocols. Compliance to the various modalities varied considerably between studies and, in general, was poorest during the postoperative period. The use of epidural had the highest compliance (between 67 and 100%), whereas the use of transverse incisions (25%) had the lowest compliance. Length of stay in hospital ranged from 2 to 13 days. Those studies with higher compliance were associated with a reduced length of stay. However, reduced length of stay was associated with high rate of readmission.

Conclusion:  There is significant variation in the components of ERAS protocols as well as their compliance in daily practice. This may contribute to the observed variation in length of stay between the studies. A standardized and practically feasible ERAS protocol should be established in order to improve the implementation and optimum outcome.

Background:  The aim of the study was to evaluate the efficacy and safety of fast track rehabilitation in elderly patients over 65 years following laparoscopic surgery to remove colorectal cancer.

Method:  A total of 78 elderly patients with colorectal cancer who underwent laparoscopic colorectal resection were randomly assigned to receive either the fast track care program (FT group, N = 40) or the conventional perioperative care protocol (control group, N = 38). Medical personnel conducting the study were blinded to patients’ clinical outcomes prior to statistical analysis. The fast track protocol included no preoperative mechanical bowel irrigation, immediate oral alimentation and earlier ambulation exercise post-operation. The length of postoperative hospital stay, the length of time for the regain of bowel function and the rate of postoperative complications were compared between two groups.

Results:  The length of time for regained bowel function, including passage of flatus, (31 [26-40] h vs. 38[32-51] h, p = 0.001); bowel movement (55 [48-63] h vs. 64[48-71] h, p =0.009); and the time to liquid diet (12 [11-16] h vs. 47[35-50] h, p = 0.000) were significantly shorter in patients with the fast track care protocol compared to those in patients with the conventional care. Shorter duration of postoperative hospital stay was recorded in patients with fast track program than that in the control group (p=0.0001). A reduced percentage of patients who developed general complications was also observed in FT group (5.0% vs 21.1%., p= 0.045).

Conclusions:  This randomized controlled trial has shown that in the elderly undergoing laparoscopic colorectal surgery, the fast track recovery program demonstrated a more rapid postoperative recovery, earlier discharge from hospital and fewer general complications compared to a conventional postoperative protocol.

Aim: Background: The annual scientific meetings of the Association of Coloproctology of Great Britain and Ireland (ACPGBI), the American Society of Colon and Rectal Surgeons (ASCRS), the European Society of Coloproctology (ESCP) and the Royal Australasian College of Surgeons (RACS) are the major fora for presentation of colorectal surgical research. Thus, their content could be a proxy of the content and quality of colorectal surgical research worldwide. We aimed to critically appraise the quantity, quality and topics of colorectal surgical research across over the previous five years for the above meetings.

Method:  All published abstracts from the ACPGBI, ESCP, ASCRS, and colorectal-specific component of RACS from 2006 to 2010 were appraised. Abstracts were coded by predefined categories pertaining to study type and topic.

Results:  Level 1 evidence (systematic reviews/meta-analyses) and level 2 evidence (randomised controlled trials) comprised 3% (95%CI 1-9%) and 5% (95%CI 2-11%) respectively, of research presented at the meetings. There was a predominance of level 4 evidence (retrospective studies) across all years (mean 54%, 95%CI 44-68%). Operative management was most commonly studied (mean 43%, 95%CI 36-49%). There was minimal research in peri-operative care (mean 6%; 95%CI 2-13%) and basic surgical science (mean 6%; 95%CI 2-11%). Research related to peri-operative care was significantly higher at the ACPGBI and RACS meetings compared to the ASCRS and ESCP meetings (p<0.01).

Conclusion:  The research at these meetings consists largely of retrospective reviews exploring operative management with minimal high quality scientific content. Active steps need to be taken to increase the quantity of high level evidence especially in topics other than operative management.

Aim:  In guaiac faecal occult blood test (gFOBT) screening at least 50% of positive individuals will have a colonoscopy negative for colorectal neoplasia. The question of continuing screening in this group has not been addressed.

Method:  Data on participants aged 50-69 years with a positive gFOBT result and a negative colonoscopy were followed through the biennial screening pilot conducted between 2000 and 2007 in Scotland.

Results:  In the first screening round, 1527 colonoscopies were negative for neoplasia. 1300 were re-invited in the second round, 905 accepted, and 157 had a positive gFOBT result giving a positivity rate of 17.4%. Colonoscopy revealed 20 subjects with adenoma and six with invasive cancer. 1031 were invited for a third time in the third screening round and 730 accepted: 55 had a positive gFOBT test, giving a positivity rate of 7.5%. In this group, six colonoscopies revealed adenomas but there were no cancers diagnosed. In the third screening round, 108 individuals had had two positive gFOBT results and two subsequent negative colonoscopies. 84 were invited for a third gFOBT, 66 accepted and 19 (25.6) had a positive result none of whom had an adenoma or carcinoma.

Conclusion:  These data indicate that a negative colonoscopy following a positive gFOBT is not a contraindication for further screening, although this is likely to have a low yield of neoplastic pathology after two negative colonoscopies.

Aim:  The extra-levator abdominoperineal excision (APE) of the rectum has been introduced with the aim of improving the oncological outcome of low rectal cancer. The procedure includes resection of the levator muscles en bloc with the mesorectum, leaving a larger perineal defect than after conventional, APE. This study reports short term outcome of gluteus maximus myocutaneous flap reconstruction on perineal wound healing.

Method:  65 patients were studied after extra-levator APE and a one sided myocutaneous flap for a low or locally recurrent rectal cancer at the Karolinska University Hospital from January 2002 to December 2008. Fifty nine had received neoadjuvant radio- or radiochemotherapy. All perineal complications occurring within 30 days after surgery were registered. In addition, the status of the perineal reconstruction at six months and one year after surgery was assessed based on medical records from outpatient visits.

Results:  Twenty seven (41.5%) patients had one or more perineal wound complications. A minor wound infection occurred in 15 while 12 had either a more severe infection with dehiscence or a pelvic abscess. The reconstruction was completely healed in 91% of the patients at one year.

Conclusion:  Although the vast majority of the perineal reconstructions were healed at one year, the short term perineal wound complication rate of gluteus maximus flap reconstruction was high.

Aims:  Random colonic biopsies are recommended to exclude microscopic colitis in patients with chronic diarrhoea especially when mucosa is macroscopically normal at endoscopy. This study aimed to assess the clinical outcome and economic impact of such a policy in an unselected group of patients with macroscopically normal mucosa.

Methods:  All new patients undergoing colonoscopy for investigation of chronic diarrhoea between April and December 2009 were included. Patients were divided into two groups: ‘macroscopically normal mucosa’ (MNM) and ‘macroscopically inflamed mucosa’ (MIM). Endoscopic findings were correlated with histology of random biopsies and hematological parameters. Symptom status and any treatment were established from follow-up. The breakdown and overall cost of random biopsies for each patient with a MNM was determined, and cost incurred per diagnosis of microscopic colitis was established.

Results:  Altogether 137 (90.1%) out of 152 patients with chronic diarrhoea had MNM at colonoscopy. Overall incidence of microscopic colitis in the study was 1.3% (2/152), both patients belonged to MNM group. At follow-up, both these patients had spontaneous symptom resolution without any specific treatment. The policy of undertaking random biopsies in patients with MNM incurred an extra cost of £22,057 to diagnose two cases of microscopic colitis but did not alter medical treatment.

Conclusions:  In unselected patients with chronic diarrhoea and macroscopically normal mucosa, random colonic biopsies have a low diagnostic yield and incur a high cost. Continued research for predictive markers to improve patient selection for targeted biopsies is needed to develop a cost-effective investigative algorithm in chronic diarrhoea.

Introduction:  We sought to identify the rate of reoperation after an index colorectal surgical procedure and potential contributing risk factors.

Methods:  This is a retrospective cohort study from the American College of Surgeons National Surgical Quality Improvement Program. We identified all patients who either returned, or did not return to the operating room after any colorectal resection from 1/2005 through 12/2008.

Results:  From a total cohort of 635, 265 patients included in the National Surgical Quality Improvement Program over the four year study period, we identified 54,237 patients who underwent colorectal operations. A return to the operating room was coded in 5.4±0.1% of non-colorectal resection patients and 7.6±0.2% of colorectal resection patients (p<0.001). The multivariate model identified patients with postoperative diagnostic codes for abdominal cavity hernia or colostomy complication as having the highest odds of return to the operating room within 30 days. Patients returning to the operating room had longer length of stay and higher overall mortality as compared to those patients who did not return to the operating room.

Conclusions:  Return to the operating room is a relatively common occurrence after colorectal resections, with an associated high rate of mortality. Given the association between return to the operating room and adverse patient outcomes, emphasis should be placed on determining strategies to reduce the need for return to the operating room.

Background and aim:  Duodenal adenomatosis in FAP results in a cancer risk that increases with age. Endoscopic surveillance has been recommended, but the effect has not yet been documented. The aim of this study is to present results of long-term duodenal surveillance and to evaluate the risk of cancer development.

Method:  Follow-up of patients in a previous study with gastroduodenoscopy in 1990-2010. Statistical analysis included chi² test, actuarial method and Kaplan-Meier analysis.

Results:  Among 304 patients, 261 (86%) had more than one endoscopy. The median follow-up was 14 years (interquartile range 9-17). The cumulative lifetime risk of duodenal adenomatosis was 88% (95% CI 84-93), and of Spigelman stage IV 35% (95% CI 25-45). The Spigelman stage improved in 32 (12%), remained unchanged in 88 (34%) and worsened in 116 (44%). Twenty patients (7%) had duodenal cancer at a median age of 56 years (range 44-82). The cumulative cancer incidence was 18% at age 75 (95% CI 8-28) and increased with increasing Spigelman stage at the index endoscopy to 33% in stage IV (p<0.0001). The median overall survival was 6.4 years (95% CI 1.7-not estimated): 8 years after a screen-detected cancer vs. 0.8 years (95% CI 0.03-1.7) after a symptomatic cancer (p<0.0001). The location of the mutation in the APC gene did not influence the risk of developing Spigelman stage IV (p=0.46) or duodenal cancer (p=0.83).

Conclusions:  The risk of duodenal cancer in FAP is considerable, and regular surveillance and cancer prophylactic surgery result in a significantly improved prognosis.

Aim:  The study aimed to determine whether the introduction of a screening programme for colorectal cancer influenced resection and recurrence rates and prognosis.

Method:  Details of patients with a biopsy-confirmed diagnosis of colorectal cancer attending from January 2002 to December 2006, were entered into a prospective database. All were followed to death or the end of the study period (December 2008). Patients with a synchronous cancer were excluded from analysis. A comparison was made between screen and non-screen detected cancers for survival, disease free survival, location of the primary tumour, resection and recurrence rates.

Results:  841 (median age of 72 (30-101) years; 53% male) patients with colorectal cancer were identified,. Of these 68 were screen detected of whom 63 underwent surgery. Screen detected cancers were significantly less advanced at presentation (p=0.001). There was no significant difference in primary tumour location between screen and non-screen detected cancers, (p=0.184). Among curative resections, significantly fewer screened compared with non-screened cancers developed a recurrence (6/59[10.2%] v 105/491 [21.4%], p=0.043). The mean disease free survival for screen and non-screen detected cancers was 78.3 months and 65.0 months (p=0.010). Overall mean survival was significantly improved for screened (73.8 months) over non-screened (57.9 months) detected cancers, p=0.001.

Conclusion:  Screening for colorectal cancer in this population significantly improved overall cancer-related and disease free survival, possibly as a result of the detection of significantly more early staged cancers.

Aim:  The aetiology of colonoscopic perforation and factors related to poor outcome of surgical treatment were studied.

Method:  A single centre review was conducted of all patients who underwent surgical treatment of a colonoscopic perforation, identified from a prospective registry of 21981 consecutive colonoscopies carried out between 1993-2009.

Results:  There were 29 (8 female) patients of mean age 73 years including 10 who had a non-elective colonoscopy. The perforation was not immediately recognized in 12 patients and in the remaining 17 seven were initially managed conservatively. The causes of perforation were barotrauma (11), mechanical force (14) and polypectomy-related (3). Barotrauma was more frequent in emergency colonoscopy and mechanical force in elective colonoscopy. The outcome of surgery was as follows: mortality 10%, complications 34.5%, reoperation 14%, secondary surgery 23% and permanent colostomy 3%. The only factor related to in-hospital mortality was an increased ASA score.

Conclusion:  Colonoscopic perforation requiring surgery is a catastrophic event with high mortality, morbidity and reoperation rates.

Aim:  The aim of the study was to determine the long-term outcome, recurrence rate and faecal incontinence score after fissurectomy for chronic anal fissure (CAF) not responding to conservative treatment.

Method:  53 consecutive patients (29 women) who underwent fissurectomy for a medically resistant CAF between 1998 and 2005 were included in the study. At a minimum follow up of five years a standardized questionnaire was sent to all patients, assessing recurrence, satisfaction with the operation (0-10) and faecal continence (Vaizey score: 0-24). The patients were compared with a control group of 50 healthy volunteers, matched for sex and age, who had never undergone anal surgery.

Results:  43 (81%) patients (25 female) returned the questionnaire. The mean age was 40 years (sd 12.1) and median follow up was 8.2 (5.5-12.2) years. Five patients had a recurrent CAF (11.6%). 90% of patients would have consented to the operation again if necessary. The mean Vaizey score at follow up was 2.5 (+/-4.2 SD). The mean Vaizey score of the four patients who had had a previous lateral sphincterotomy was 3.8 and for the 8 patients who had reported a continence disturbance before fissurectomy it was 8.3. The mean Vaizey score of the 31 patients who were continent before fissurectomy was 0.8 compared with 0 .4 in the control group (p=.9).

Conclusion:  At five years or more fissurectomy for medically resistant CAF is effective with a low recurrence rate and minimal influence on continence.